Walsingham House
35 Seething Lane
LondonEC3N 4AH
Tel +44 20 7090 1460
info@ics-shipping.org | ics-shipping.org
This Circular and its attachments (if any) are confidential to the intended recipient and may be privileged.
If you are not the intended recipient, you should contact ICS and must not make any use of it.

25 July 2022
TO:

COVID-19(22)15

LABOUR AFFAIRS COMMITTEE
ALL MEMBERS & ASSOCIATE MEMBERSBIWEEKLY MEMBERS MEETING PARTICIPANTS
INTERNATIONAL ASSOCIATION GROUP PARTICIPANTS

COVID-19 UPDATE and MONKEYPOX UPDATE AS OF 25 July 2022
Action Required: Globally, as of 22 July 2022, there have been 565,207,160 confirmed
cases of COVID-19, including 6,373,739 deaths, reported to WHO. As of 19 July 2022,
a total of 12,219,375,500 vaccine doses have been administered.
SITUATION IN NUMBERS BY WHO REGION

GlobalAmericasCases
565,207,160
168,183,683

Deaths6,373,739
2,779,572

EuropeSouth-East Asia
Eastern Mediterranean
AfricaWestern Pacific

237,944,384
59,076,731
22,398,987
9,181,118
68,421,493

2,041,618
791,463344,284
173,921242,868

TOP 12 COUNTRIES
1
2
3
4
5
6
7
8
9

USA
India
BrazilFranceGermany
UK
Italy
Korea
RussiaMOST CASES YESTERDAY
Japan
USA
Italy
FranceGermany
Korea
BrazilAustralia
MexicoHIGH FATALITIESYESTERDAY
USA
BrazilItaly
FranceMexicoAustralia
China
Chile
RussiaRegistered Office Walsingham House, 35 Seething Lane, London, EC3N 4AH
Registered in England and Wales No. 2532887

10
11
12

Turkey
Spain
Japan

China
Peru
Austria

Japan
Korea
Peru

The WHO Director-General has determined that the multi-country outbreak of monkeypox
constitutes a Public Health Emergency of International Concern, following the International
Health Regulations (2005) (IHR) Emergency Committee regarding the multi-country
outbreak of monkeypox, held on Thursday, 21 July 2022, from 12:00 to 19:00 CEST. The
EC
reportandtemporaryrecommendationsareavailableathttps://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-healthregulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-ofmonkeypox
https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox

Please find the statement on the twelfth meeting of the IHR (2005) Emergency Committee
regarding the COVID-19 pandemic, held 8 July 2022, available at the following link:
https://www.who.int/news/item/12-07-2022-statement-on-the-twelfth-meeting-of-theinternational-health-regulations-(2005)-emergency-committee-regarding-thecoronavirus-disease-(covid-19)-pandemic. The WHO Director-General concurs with theadvice offered by the EC and determined that COVID-19 continues to constitute a Public
Health Emergency of International Concern (PHEIC).
COVID-19(22)15 -Annex 1 - facilitating safe crew changes and supporting seafarer
wellbeing during covid-19
COVID-19(22)15 -Annex 2 - Weekly_Epi_Update
COVID-19(22)15 -Annex 3 - ICAO Travel Testing Report 19 Jul_ 2022
COVID-19(22)15 -Annex 4 - ICAO Vaccination Report 19 July_ 22
COVID-19(22)15 -Annex 5 - Preliminary-public-health-considerations- COVID-19vaccination-2022
COVID-19(22)15 -Annex 6 - Joint ECDC-WHO Regional Office for Europe Monkeypox
Surveillance Bulletin_2022-07-20
COVID-19(22)15 -Annex 7 - KEEPING AGENTS SAFE ON BOARD - INFECTIOUS
DISEASES PROTOCOLS - JULY 2022
COVID-19(22)15 -Annex 8 - JSA updates
Ondrilla Fernandes
Employment Affairs Advisor

FACILITATING SAFE CREW CHANGESAND SUPPORTING SEAFARERWELLBEING DURING THE COVID-19
PANDEMIC

Version 1
March 2022*

The EU HEALTHY GATEWAYS Joint Action has received funding from the European Union, in the framework of the Third Health Programme(2014-2020). The content of this document represents the views of the author only and is his/her sole responsibility; it cannot be considered
to reflect the views of the European Commission and/or the European Health and Digital Executive Agency (HaDEA) or any other body of
the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information
it contains.
*1

Contents
1. Introduction ............................................................................................................................ 6
2. Purpose and scope .................................................................................................................. 7
3. Preventive measures in place at all times on board .................................................................. 7
3.1.

Written contingency plan/outbreak management plan .........................................................7

3.2.

Routine screening tests ...........................................................................................................8

3.2.1.

Frequency of routine screening/diagnostic testing.........................................................8

3.2.2.

Acceptable diagnostic tests .............................................................................................93.2.3.

Recommended supplies and equipment for screening and general measures ..............9

4. Options for measures to prevent introduction of COVID-19 on board ..................................... 10
5. Response to a COVID-19 event on board ................................................................................ 13
5.1.

Management of possible/confirmed case ............................................................................135.1.1.

Reporting to the next port of call ..................................................................................14

5.1.2.

Disembarkation ..............................................................................................................14

5.1.3.

Cleaning, disinfection and waste management ............................................................14

5.1.4.

Management of contacts...............................................................................................15

5.2 Overview of general measures to mitigate COVID-19 transmission and considerations for theseafarer’s journey ..................................................................................................................15
6. Public health measures during shore-side visit ....................................................................... 20
7. Journey from the ship to home .............................................................................................. 20
8. Considerations for crew vaccinations ..................................................................................... 20
9. Supporting seafarer welfare and safeguarding mental and physical health ............................. 229.1. Seafarer access to health care ....................................................................................................22
9.2 Seafarer access to psychological assistance and mental health services ...................................23
10. Annexes............................................................................................................................... 24
11. References ........................................................................................................................... 292

Abbreviations
CDC

Centers for Disease Control and Prevention

COVID-19

Coronavirus disease

DG MOVE

Directorate-General for Mobility and Transport

ECDC

European Centre for Disease Prevention and Control

EMA

European Medicines Agency

EMSA

European Maritime Safety Agency

EU

European Union

EU MS

European Union Member States

ICAO

International Civil Aviation Organization

ICS

International Chamber of Shipping

IHR

International Health Regulations

ILO

International Labour Organization

IMO

International Maritime Organization

ISWAN

International Seafarers Welfare and Assistance Network

IVD

In Vitro Diagnostic

JRC

Joint Research Centre

MDH

Maritime Declaration of Health

MLC

Maritime Labour Convention

NAAT

Nucleic Acid Amplification Test

RT-PCR

Reverse transcription - Polymerase chain reaction

POE

Point of entry

PPE

Personal protective equipment

RADT

Rapid antigen detection test

SARS-CoV-2

Severe acute respiratory syndrome coronavirus 2

VOC

Variants of concern

WHO

World Health Organization

3

Definitions
Cycle threshold (Ct) value: Real-time reverse transcription (RT)-PCR tests are the gold standard for the detection of COVID19 and provide both a qualitative result (detected/not detected) and a quantitative result in the form of a cycle threshold(Ct) value (number of amplification cycles required for the detection signal to cross the background level - i.e. to generate apositive result). As Ct values are determined by the amount of viral RNA in the sample, they are often used as a proxy for theviral load (defined as the quantity of virus particles or viral genome copies in a given volume of the specimen) and can relate
to the amount of virus present in the specimen (source: Infection, updated 17 March 2022.
https://www.ecdc.europa.eu/en/covid-19/latest-evidence/infection).
Confirmed COVID-19 case: Any person that SARS-CoV-2 nucleic acid or antigen is detected in a clinical specimen. Rapid
antigen test should be performed within 5 days from symptom onset or within 7 days from time of exposure. If the exposure
time is unknown, the rapid antigen test should be performed as soon as possible (source: Case definition for COVID-19, as of
3 December 2020. https://www.ecdc.europa.eu/en/covid-19/surveillance/case-definition).
Face mask: Overarching term used for any device (i.e. a community face covering, medical face mask or a respirator) that isworn over the mouth and nose to prevent the inhalation of harmful substances such as infectious respiratory droplets or the
release of infectious respiratory droplets produced by breathing, speaking, coughing or sneezing in the environment (source:
Considerations for the use of face masks in the community in the context of the SARS-CoV-2 Omicron variant of concern. 7
February 2022.
https://www.ecdc.europa.eu/en/publications-data/using-face-masks-community-reducing-covid-19transmission).
Incubation period: Time between exposure to a virus and the development of symptoms (incubation period of COVID-19 isfive to six days on average - range: two to 14 days) (source: Infection, https://www.ecdc.europa.eu/en/covid-19/latestevidence/infection).
Isolation: separation of ill persons from others in such a manner as to prevent the spread of infection or contamination(source: International Health Regulations 2005, 3rd Edition. https://www.who.int/publications/i/item/9789241580496).
Medical face mask (also known as surgical or procedure mask): Disposable medical device used by healthcare workers toprevent large respiratory droplets and splashes reaching the mouth and nose of the wearer, and as a means of source control
to stop the spread of large respiratory droplets by the person wearing them. Requirements for medical face masks, including
the duration of use, are defined in the European Committee for Standardization’s published standards. Medical face masks
are not defined as personal protective equipment in Regulation (EU) 2016/425 of 9 March 2016 or Directive 89/656/EEC on
personal protective equipment. However, for the purpose of this document and in accordance with guidance on infection
prevention and control in the context of COVID-19 by the World Health Organization (WHO) and on transmission-based
precautions, medical face masks are considered to provide protection against infections transmitted by droplets (source:
Considerations for the use of face masks in the community in the context of the SARS-CoV-2 Omicron variant of concern. 7
February 2022.
https://www.ecdc.europa.eu/en/publications-data/using-face-masks-community-reducing-covid-19transmission).
Nucleic Acid Amplification Test (NAAT): RT-PCR or other NAAT, which should have the CE certification marking and should
be in the list of the Joint Research Centre (JRC) In Vitro Diagnostic (IVD) database (https://covid-19diagnostics.jrc.ec.europa.eu/) or in the list of US Food and Drug Administration with the In Vitro Diagnostics Emergency Use
Authorization – Molecular Diagnostic Tests for SARS-CoV-2 and authorised for screening (testing asymptomatic individuals
without known exposure) and can be used as specified in the authorization list for certified laboratories or health caresettings:
https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizationsmedical-devices/in-vitro-diagnostics-euas-molecular-diagnostic-tests-sars-cov-2#individual-molecular. Further information
on diagnostics can be found on “FIND”, the global alliance for diagnostics: https://www.finddx.org/
Possible case of COVID-19: Any person with at least one of the following symptoms: runny nose, sore throat, headache,cough, fever, shortness of breath, sudden onset of anosmia, ageusia or dysgeusia, vomiting or diarrhoea. Additional lessspecific symptoms may include chills, muscle pain, fatigue (Source: https://www.ecdc.europa.eu/en/covid-19/latestevidence/clinical ).
Public health observation: Monitoring of the health status of a traveller over time for the purpose of determining the risk of
diseasetransmission(source:
International
HealthRegulations
2005,
3rd
Edition.
https://www.who.int/publications/i/item/9789241580496).

4

Quarantine: restriction of activities and/or separation from others of suspect persons who are not ill in such a manner as toprevent the possible spread of infection or contamination (source: International Health Regulations 2005, 3rd Edition.
https://www.who.int/publications/i/item/9789241580496).
Rapid antigen detection test (RADT): Any type of RADT listed in the document “Common list of COVID-19 rapid antigen tests,
including those of which their test results are mutually recognised, and a common standardised set of data to be included in
COVID-19 test result certificates” (source: European Commission Directorate-General for Health and Food Safety. Publichealth, country knowledge, crisis management Health Security. Agreed by Health Security Committee on 17 February 2021.
An
updatedtoAnnex
IIagreed
by
HSC
on
19
March
2021.
https://ec.europa.eu/health/sites/health/files/preparedness_response/docs/covid-19_rat_common-list_en.pdf).
Respirator (also known as a filtering face piece (FFP) mask or filtering half mask): device designed to protect the wearerfrom exposure to airborne contaminants (e.g. from inhaling dust or infectious particles). Requirements for FFPs, including
the intended duration of use, are specified in the European Committee for Standardization’s published standards, andrespirators are classified as personal protective equipment. An N95/N99 respirator is the United States’ equivalent of
FFP2/FFP3 respirators as defined by US standard NIOSH 42 CFR, part 84. The KN95/KP95 standards (China) has similar
performance requirements (source: Considerations for the use of face masks in the community in the context of the SARSCoV-2 Omicron variant of concern. 7 February 2022. https://www.ecdc.europa.eu/en/publications-data/using-face-maskscommunity-reducing-covid-19-transmission).
Vaccinated individuals: a seafarer who carries a proof of vaccination, and at least 14 days and no more than 270 days havepassed since the last dose of the primary vaccination series or if the person has received a booster (i.e. 3rd dose) dose(exceptions apply for persons under the age of 18) †. The above definition of vaccinated individual is based on the current
European Commission definition. Should the European Commission definition change, the definition of vaccinated individualin this document will change accordingly. Heterologous vaccination is acceptable as indicted in the EMA and WHO
recommendations1,2‡.
Acceptable vaccines are considered those listed in the European Medicines Agency (EMA) or WHO lists.

Listed vaccine (as of 18 March 2022)*

EMA list

WHO list

Doses in Series

Type

1
2
3
4
5
6
7
8
9

Yes
Yes
Yes
Yes
Yes
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

2
2
1
2
2
2
2
2
2

mRNA
mRNA
Vectored
VectoredProtein subunit
Inactivated
Inactivated
InactivatedProtein subunit

Comirnaty (BioNTech and Pfizer)
Spikevax (Moderna)
Janssen (Johnson & Johnson)
Vaxzevria (AstraZeneca, Covishield)
Nuvaxovid (Novavax)
Sinopharm
Sinovac-CoronaVac
Covaxin
Covovax*Updates can be found in: https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirusdisease-covid-19/treatments-vaccines/covid-19-vaccines
andhttps://www.who.int/emergencies/diseases/novelcoronavirus-2019/covid-19-vaccines† Certificates held by persons aged 18 and above indicating the completion of the primary vaccination series shall be accepted

only if not more than 270 days have passed since the date of the latest dose in that series‡ Depending on product availability, countries implementing WHO EUL inactivated vaccines for initial doses may consider
using WHO Emergency Use Listing (EUL) vectored or mRNA vaccines for subsequent doses.
• Depending on product availability, countries implementing WHO EUL vectored vaccines for initial doses may consider using
WHO EUL mRNA vaccines for subsequent doses.
• Depending on product availability, countries implementing WHO EUL mRNA vaccines for initial doses may consider using
WHO EUL vectored vaccines for subsequent doses.

51. Introduction
The EU HEALTHY GATEWAYS Joint Action (Grant Agreement No 801493) in collaboration with theEuropean Commission’s Directorate General for Mobility and Transport (DG MOVE) have jointly
developed this document.
As indicated by the International Maritime Organization (IMO), more than 80% of the tradevolume globally is transported by ships. Seafarers’ work is essential to maintain supply chains offood, medical products, energy and other goods globally. During the COVID-19 pandemic seafarers
were dramatically affected due to travel restrictions and were unable to perform crew changes,
with thousands stranded on board ships for several months. Efforts of the shipping industry andgovernmental authorities are essential to protect seafarers’ health and wellbeing, while at thesame time allowing for safe movements and crew changes.
This document was produced considering Communications and Recommendations issued by theEuropean Commission on travel and transport during the coronavirus disease (COVID-19)
pandemic3. Current evidence on COVID-19, recommendations and guidance from the World
Health Organization (WHO)4, technical reports from the European Centre for Disease Prevention
and Control (ECDC)5 and relevant Circular Letters of the IMO6 as of March 2022 were also taken
into account.
Commercial vessels are semi-closed workplaces with common facilities that promote close
contact, enabling COVID-19 transmission. It is important that ship owners, crew managers andother ship operators (or their representatives) ensure public health measures are in place toprevent introduction, as well as on board transmission among seafarers, from seafarers to shipvisitors (e.g. persons involved in ship/shore interface, maritime/shore-based/port personnel) or
conversely from ship visitors to seafarers. Risks for COVID-19 transmission also exist during
seafarers’ entire journey travelling from their place of residence to the ship and returning. With
on-going COVID-19 transmission continuing to be reported worldwide, variants of concern (VOCs)
present in many countries, and uneven COVID-19 vaccination coverage of seafarers, this group is
at risk during any point of their journey. Measures should also be in place to prevent COVID-19
infectious seafarers from beginning their journey or boarding the vessel, and at the same time
while on board facilitating seafarers’ opportunities for shore-side visits and supporting theiraccess to healthcare and mental health services.
While this document focuses on providing practical guidance related to COVID-19, the guidance
and procedures included within (e.g. preventive measures to be in place at all times on board,
responding to an event, supporting seafarers’ welfare and safeguarding mental/physical health)
are more widely applicable. Measures for commercial vessels included in this document can beapplied to other similar respiratory illnesses that are easily transmitted on board such as Influenza,
as well as to new emerging pathogens and during future public health emergencies.
Provision of medical care and support without delay on board is essential as commercial vessels
undertake extended journeys and may be away from land-based health facilities for long periods.
This is essential especially during the pandemic since due to the nature of their work, unavoidable
close contact in the shipboard accommodation and with limited access to land-based care,seafarers are at greater risk if they contract COVID-19 and cannot receive prompt and appropriate
care.

6

2. Purpose and scope
The purpose of this document is to provide practical guidance for ship owners, crew managers
and ship operators (or their representatives) for measures on commercial vessels that should be
implemented to protect the health of seafarers and safe seafarer travel in the European Union(EU) context. This document does not contain legally binding guidance, but is based on existing
published recommendations and guidelines from the European Commission and EU agencies. This
document has not been developed to provide guidance to governmental authorities or port
administrations, since European Commission Recommendations as well as other guideline
documents have been published by EU agencies – including ECDC and the European Maritime
Safety Agency (EMSA) – addressing recommendations for actions by governmental authorities(Annex 1). The document should also be read in conjunction with other documentation provided
by WHO and the International Chamber of Shipping (ICS) in relation to ships sailing on
international voyages.
For the purpose of this document, a commercial vessel does not include passenger cruise orpassenger ferry vessels. EU HEALTHY GATEWAYS has developed specific guidance for passenger
cruise and passenger ferry ships in the context of COVID-19§. This current guidance describes
measures for public health observation and for preventing the introduction of COVID-19 on board
vessels, screening and diagnostic testing for COVID-19 and reducing risks for transmission amongseafarers covering their entire journey, beginning from their home to the ship and back.
Considerations are further provided to facilitate seafarers’ shore-based visits when at a port ofcall and to safeguard seafarers’ health and welfare. Any national or local guidelines, policies andregulations relevant to the scope of the current document, enacted by European Union Member
States (EU MS) which are stricter than the current document guidelines and addressed to shipowners or their representatives, should be implemented in addition to the current guidelines.

3. Preventive measures in place at all times on board
3.1. Written contingency plan/outbreak management plan
A written contingency plan/outbreak management plan for the commercial vessel should be inplace for detecting and responding to a COVID-19 event on board. The plan should be tested
through exercises.
The plan should outline the following procedures related to7:
• Detection of COVID-19 cases (e.g. protocols for surveillance and monitoring, including
testing frequency)• Reporting and notification of an incident on board• Management of possible/confirmed COVID-19 cases and their contacts (including
protocols for isolation and quarantine)• Disembarkation of cases and their contacts, including transport to a land-based
medical facility if required• Personal protective measures (e.g. protocols for face mask use, physical distancing,hand hygiene etc.) and environmental measures (e.g. protocols for routine and§ EU

HEALTHY GATEWAYS guidance in the context of COVID-19 for passenger cruise ships and passenger ferries(https://www.healthygateways.eu/Novel-coronavirus#Interim)7•enhanced cleaning and disinfection measures if an event takes place on board,
protocols for ventilation of ship areas)
Plan for communication (internal communication procedures and for communication
with competent authorities at the port)

Box 1: Essential information and instructions for raising seafarer awareness to detect COVID-19 cases

Raising seafarer awareness for detecting and managing a COVID-19 event on board
Ship owners, crew managers and ship operators (or their representatives) should provide seafarers withinformation and instructions in English and if possible in their national language, related to their role in theimplementation of the ship’s contingency plan/outbreak management plan, the detection and managementof possible/confirmed COVID-19 cases and contacts on board, as well as other necessary information.
All seafarers on board should receive instructions about the following:• Ship’s written contingency plan and their specific role in plan implementation• COVID-19 compatible signs and symptoms• On board procedures in the event that a seafarer displays relevant COVID-19 symptoms• Special considerations for high-risk groups on board• Personal protective and hygiene measures implemented on board the vessel (e.g. protocols for face maskuse, physical distancing, hand hygiene etc.)• Environmental measures implemented on board the vessel (e.g. protocols for routine and enhanced
cleaning and disinfection measures if an event takes place on board, protocols for ventilation of ship
areas)In accordance with the Maritime Labour Convention (MLC) 2006, as amended (MLC, 2006)8 “ships which do
not carry a medical doctor shall be required to have either at least one seafarer on board who is in charge of
medical care and administering medicine as part of their regular duties or at least one seafarer on board
competent to provide medical first aid; persons in charge of medical care on board who are not medical
doctors shall have satisfactorily completed training in medical care that meets the requirements of theInternational Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as
amended (“STCW”)…..”
Seafarer on board in charge of medical care/competent to provide medical first aid should receive instructions(in addition to above) about the following:• Care of possible/confirmed COVID-19 cases• Procedures if event detected on board (e.g. protocols for isolation and quarantine)
Guidance related to COVID-19 case management on board are available from WHO 7 and ICS9.

3.2. Routine screening tests
The following section describes the suggested frequency of screening during routine
operations (excluding the period of public health observation conducted on board). It further
provides guidance on the recommended supplies and equipment to be carried on board forboth routine screening and to respond to a COVID-19 case or outbreak on board.
3.2.1. Frequency of routine screening/diagnostic testing
As COVID-19 cases may be introduced on board during the ship’s voyage, a protocol of routine
screening is recommended. The frequency can be determined following a risk-based approach.
Rapid Antigen Detection Tests (RADTs) should be conducted on all seafarers on board, but
giving priority to unvaccinated seafarers in any situation that could pose a risk of infection.

8

3.2.2. Acceptable diagnostic tests
As described in the definition section of this document, any type of RADT listed in the European
Commission document “Common list of COVID-19 rapid antigen tests, including those of which
their test results are mutually recognised, and a common standardised set of data to be
included in COVID-19 test result certificates”** and/or the WHO “Emergency Use Listing for In
vitro diagnostics (IVDs) Detecting SARS-CoV-2-RADTs lists” †† is suggested for use of routine
screening on board.
3.2.3. Recommended supplies and equipment for screening and general measures
Ship owners, crew managers and other ship operators (or their representatives) should ensurein accordance with the MLC 20068, that if a medical doctor is not on board, at least one seafarer
on board will be in charge of medical care and administering medicine as part of their regularduties, or at least one seafarer on board is competent to provide medical first aid and medicalcare to possible/confirmed COVID-19 cases on board and their contacts. This designatedseafarer should be trained to perform clinical specimen collection and testing with RADTs,
particularly if on extended voyages where access to land-based facilities will be very limited.
It should also be ensured that adequate medical supplies and equipment are available for
symptomatic treatment of COVID-19 (e.g. antipyretics) and other health conditions, as
described in the WHO (2007) recommended medicines and equipment by the International
Medical Guide for Ships 3rd edition10, or as per country medical guidance published by national
authorities. Thermometers accurately measuring body temperature should be available onboard. An adequate supply of personal protective equipment (PPE) should be available onboard with ship owners, crew managers and other ship operators (or their representatives)
considering the number of seafarers on board, the embarkation of ship visitors, the durationof the voyage and the possibility of shore-side visits by seafarers.
Box 2: Essential supplies and equipment to be available at all times
Essential supplies and equipment
An adequate supply of the following should be available at all times on board for routine preventive measuresand if needed to respond to a COVID-19 case or outbreak:
RAPID ANTIGEN DETECTION TESTS:• The number needed should be calculated based on the vessel capacity and frequency of routine
screening described in Section 3.2.1. For example, ship owners, crew managers and ship operators (ortheir representatives) could plan to carry on board a stockpile as follows:▪ 2 RADTs per seafarer per week (for the duration of the planned voyage)▪ 1 additional RADT per seafarer per two weeks
Ship owners should ensure continuous monitoring and replenishment of RADT stockpiles on board.
PERSONAL PROTECTIVE EQUIPMENT:• Respirators (e.g. FFP2 or equivalent standard) if available and medical face masks• Eye protection (goggles or face shields)• Disinfectants and hand hygiene supplies, tissues and no-touch bins for waste disposal• Disposable gloves• Long-sleeved impermeable gowns (aprons could also be included)** https://ec.europa.eu/health/sites/default/files/preparedness_response/docs/covid-19_rat_common-list_en.pdf†† https://extranet.who.int/pqweb/vitro-diagnostics/coronavirus-disease-covid-19-pandemic-%E2%80%94-emergency-use-

listing-procedure-eul-open (list updated periodically)

9

Seafarers should be instructed routinely by ship owners, crew managers and other ship operators (or theirrepresentatives) in their national language about appropriate wearing, use, removal, disposal orcleaning/storage of PPE.
Ship owners should take into consideration PPE supplies that may also be required if a possible case oroutbreak of COVID-19 occurs on board, for interaction of seafarers with any ship visitors and in the event thatshore-side visits take place11. Guidance regarding suggested PPE supplies are available from EU HEALTHYGATEWAYS12 and ICS9.

4. Options for measures to prevent introduction of
COVID-19 on board
To ensure continuous operation of the maritime sector for the maintenance of supply chains,essential services and economies, crew changes should be allowed in ports of EU MS, minimizing
as far as possible the impact from restrictions on seafarers. European Commission
Recommendations, Communications and Guidelines related to facilitating crew changes during
the COVID-19 pandemic can be found in Annex 1.
For the purposes of crew changes, the first part of a seafarers’ journey is the period of time toreach the ship, including time spent in their country of origin before leaving home, travelling to
the country of destination where they will embark the ship, and any time spent in the destination
country before embarking. Since seafarers may be exposed to COVID-19 at any point during thisperiod, when implementing measures in accordance with the countries’ and companies’ policies,
ship owners, crew managers and other ship operators (or their representatives) should ensure
seafarers are supported and public health measures are in place to mitigate the risks oftransmission during any point in this journey. It is also important that when on board, measures
are in place to prevent and limit as much as possible transmission of COVID-19.
Seafarers who appear fit to begin work duties may be incubating the disease in the presymptomatic period, or be asymptomatic (not presenting with COVID-19 compatible symptoms)
and infectious. It is therefore suggested to implement a risk-based approach when deciding on
establishing public health observation measures and/or testing, irrespective of potential exposure
to COVID-19, as a pre-embarkation measure for new crew. As indicated by WHO the benefits ofpublic health observation in reducing COVID-19 transmission “must be balanced against therelated risks of infringement of human rights, psychosocial and economic harm, disruption to
travel and trade, reductions in the movement of essential goods and workforce mobility”7.
It is suggested to consider different factors including COVID-19 incidence rates in the country ofseafarers’ origin and the country of embarkation, as well as the vaccination and health status ofseafarers, and then decide if necessary to define a period of public health observation for newcrew before starting regular work duties to prevent potentially COVID-19 infectious seafarers fromembarking the vessel, or if already on board to prevent and limit transmission on the vessel.
Depending on the COVID-19 incidence rates in the country of seafarers’ origin and the country ofembarkation, public health observation measures of seafarers prior to beginning their regular
work duties could take place in a designated accommodation facility ashore (e.g. hotel) or after
embarking the vessel, in addition to enhanced screening and diagnostic testing. Table 1 presents
the timeframe of work restrictions depending on the immunity status of the seafarer.

10

Table 1: Suggested duration of isolation, quarantine, public health observation and possible work restrictions
considering seafarers' health and vaccination status 13-15 (Table 1 does not address the isolation of patients that
require hospitalisation ashore)

Vaccination status ofTimeframe of work restrictions
seafarers
Work restrictions for seafarers infected with COVID-19
Resolution of fever for 24 hours and clinical improvement ofsymptoms[a]AND
Not vaccinated or not
Five days isolation[b] after the onset of symptoms
fully vaccinated, mild or AND
moderate COVID-19
Five additional days wearing a high efficiency (FFP2) mask[c]caseAND
If possible, test by RADT or RT-PCR (if RT-PCR available on board) on day
five after onset of symptoms[e]. If the ship is close to land, thenalternatively RT-PCR[d]could be conducted in a shore-side laboratory
Resolution of fever for 24 hours and clinical improvement of symptoms[a]ANDThree days isolation[b] after onset of symptoms
AND
Vaccinatedf mild or
Three additional days wearing a high efficiency (FFP2)[c] mask
moderate COVID-19
AND
case
If possible, test by RADT or RT-PCR (if RT-PCR available on board) on day
three after onset of symptoms.
If the ship is close to land, then alternatively RT-PCR[d], could be
conducted in a shore-side laboratory
Work restrictions for asymptomatic seafarers with exposure

Unvaccinatedindividuals

Vaccinated[f] individuals

Five days quarantine[g]AND
RADT or RT-PCR (if RT-PCR available on board) on day 5[h]. If the ship is
close to land, then alternatively RT-PCR could be conducted in a shoreside laboratory
AND
Five additional days wearing a high-efficiency (FFP2) mask[i]10 days wearing a high-efficiency (FFP2) mask[i]AND
RADT or RT-PCR (if RT-PCR available on board) on day 5[g] . If the ship is
close to land, then alternatively RT-PCR could be conducted in a shoreside laboratory
AND
Self-monitoring for symptoms, wearing a mask, keeping distance fromothers and avoiding contact with vulnerable populations, if possible

Work restrictions for new seafarers without infection or exposure
Vaccinated[d]Unvaccinated, even if
within 90 days of priorinfection

No work restrictions with negative RADT on days 2, 5 and 7
Public health observation for 10 days OR 7 days with negative test[a] Asymptomatic COVID-19 cases should follow the same guidance as symptomatic cases. Days should be counted from the date of thesample collection for their diagnostic test.

11

[b] When recommending a shorter duration of isolation, the residual risk of onward transmission of COVID-19 increases. Therefore, in addition
to wearing a mask, COVID-19 cases should be advised to avoid non-essential contact with other people and especially vulnerable
individuals. The end of isolation should be differentiated from the potential need for sick leave.
[c] Where a high-efficiency mask is recommended, an FFP2 (or equivalent) without a valve should be used. To be effective, these need to be
fitted properly at all times and seal testing should be performed each time the mask is put on. Fit testing is recommended, especiallyfor those working in the healthcare sector, where re-using FFP2 masks should be avoided due to heavy contamination.
[d] Testing by either RADT or RT-PCR should preferably be performed. Self-testing by RADTs is not considered adequate for ending isolation.
[e] Isolation should continue if the RADT (including self-performed) or RT-PCR test is positive on day six. If RT-PCR is performed, then high Ct
values (≥30) can be used, with caution, as a proxy of low likelihood of transmissibility. RADT can be repeated dai ly until negative or
until 10 days of isolation are completed.
[f] In this table, the term ‘vaccinated’ refers to people who:
• have received a full primary COVID-19 vaccination course within the last six months.
o The duration of protection is subject to evolving evidence and this may need to be considered.
o In areas/countries where the Omicron VOC is dominant, this period may be restricted further to three months.
o This does not apply to one-dose vaccines.
• have received a booster dose of COVID-19 vaccine.
[g] When recommending a shorter duration of quarantine, the residual risk of onward transmission of COVID-19 increases. Therefore, in
addition to mask use, individuals identified as close contacts should be advised to avoid non-essential contact with other people andespecially vulnerable individuals.
[h] Testing by either RADT or RT-PCR should preferably be performed by a qualified professional. Self-testing by RADTs is not consideredadequate for releasing from quarantine.
[i] Where a high-efficiency mask is recommended, an FFP2 (or equivalent) without a valve should be used. To be effective, these need to beworn properly at all times. Fit testing is recommended.

When deciding to place seafarers under public health observation (monitoring their health status overtime for the purpose of determining risk of disease transmission) for a specific duration of time, in
accordance with the duration of time described in Table 1, ship owners, crew managers and ship
operators (or their representatives) should make arrangements to ensure that the following are
implemented for the duration:• Self-monitoring for symptoms suggestive of COVID-19 (e.g. self-monitoring for fever bychecking temperature twice daily, recording and reporting results)• Avoiding as much as possible non-essential contact with others and use of common/shared
areas on board (mess halls, laundry rooms etc.)• Limiting interaction with other seafarers during work activities (e.g. ship owners could
assign new crew to duties where they work individually for the period of observation, if
feasible) or ensure strict measures (physical distancing of 1.5 meters and use of face mask
when working with others)• Wearing a face mask at all times when outside of individual cabins• Practicing frequent/thorough hand hygiene and respiratory etiquette• Remaining in individual cabins when not working, as much as possible• Eating meals in their cabin (if possible)• Not entering galley or pantry areas of the vessel• Transiting the vessel through outer walkways when possible
Box 3: Essential information and guidance for seafarers when undergoing public health observation
Information for seafarers
Seafarers should receive written guidance, information, instructions and material in English and if possible intheir national language from ship owners, crew managers and other ship operators (or their representatives)to support compliance with public health measures on board.
Prior to or at embarkation:• Duration of the public health observation period.
• General guidance and advice on personal protective and hygiene measures that should be observed byseafarers (proper use and management of PPE, frequent and thorough hand hygiene, proper respiratory
etiquette). If such national/local regulations do not exist, informing seafarers about adherence to aminimum standard of hygiene and protective measures (e.g. in accordance with ECDC guidance 16,17).

12

•
•
•
•

Resources and advice for the public about protective measures against COVID-19 are also available fromthe WHO18.
Procedures to follow if COVID-19 compatible symptoms develop (e.g. reporting symptoms to the shipowner and seeking medical assessment).
Protocols that should be followed to ensure compliance with public health observation measures.
Any other screening measures that may be required (e.g. visual observation, temperature measurement,
testing etc.).
Provide seafarers with appropriate and sufficient amounts of PPE, hygiene supplies and other equipment
required for the public health observation period (e.g. no-touch thermometers for monitoring ofsymptoms) with specific instructions for use.

5. Response to a COVID-19 event on board
5.1. Management of possible/confirmed caseOnce a possible or confirmed COVID-19 case is detected on board, ship owners, crew managers
and ship operators (or their representatives) should ensure that the below procedures arefollowed:
•
•

•
•

•
•

•

Activation of the written ship contingency plan/outbreak management plan as needed.
Providing the possible/confirmed COVID-19 case with a medical face mask andinforming them to practice strict respiratory etiquette and hand hygiene, especially if a
medical face mask cannot be tolerated.
Immediate isolation of the possible/confirmed COVID-19 case in the pre-designatedarea with adequate ventilation and a specific toilet facility for their use.
Ensuring that contact with the possible/confirmed COVID-19 case in isolation isrestricted to only those necessary (e.g. the seafarer on board in charge of medical care/competent to provide medical first aid) and any person entering the isolation area
wears a respirator.
Inform the next port of call about the event (see Section 5.1.1).
Test possible cases via RADT and their contacts and share the test results.
If seafarers are identified as confirmed COVID-19 cases, it is advised that they are
disembarked and isolated ashore as soon as possible following medical advice. Port
States are required to support these efforts in line with the requirements for onshore
provision of medical care and repatriation of deceased seafarers under the MLC 2006.
If disembarkation and isolation ashore is not feasible (e.g. due to lack of isolation
facilities ashore or visa issues), isolation could be carried out on board in the ship’s
isolation facilities in accordance with medical advice provided:i.
Cases are isolated separately and individually in cabins for the required periodof time, where possible. If individual isolation of cases is not possible due tospace limitations (outbreak involving many cases), accommodating confirmed
cases in the same room could be considered.
ii.
Strict control measures are implemented and isolation cabins have access tonatural light (window), where possible.
iii.
Seafarers have access to the required services, including any necessary healthcare and psychological support.

13•For the seafarers’ protection of health, ships should not depart when COVID-19 cases
have been identified among seafarers who stay on board, unless if cases havedisembarked in isolation facilities or hospitals ashore and quarantine measures areapplied for close contacts, as well as other measures in accordance with the written ship
contingency plan/outbreak management plan.

5.1.1. Reporting to the next port of call
Ship owners, crew managers and other ship operators (or their representatives) should ensurethat the International Health Regulations (IHR, 2005) are followed and that officers incommand of ships or their agents inform the competent authority of the next port of call(through the completion of the Maritime Declaration of Health (MDH) or by other means asapplicable) if a possible or confirmed COVID-19 case is detected.
5.1.2. Disembarkation
Disembarkation will be done in accordance with the instructions of the competent authority.
The following legal documents describe the obligations of governmental authorities and ship
operators about providing medical examination and treatment ashore and on board:• International Labour Organization (ILO) 2006 Maritime Labour Convention (MLC 2006):
Member States must ensure seafarers on board ships in their territory are given access to
medical facilities ashore, should they require immediate medical care, including dental care.
• IMO conventions: the International Convention for the Safety of Life at Sea (SOLAS); theInternational Convention on Maritime Search and Rescue (SAR); and the Convention on the
Facilitation of International Maritime Traffic (FAL): MS must render assistance to seafarers in
distress, including medical assistance.
- IHR: Each State Party must designate a port or ports with the capacities: (a) to provide accessto (i) an appropriate medical service including diagnostic facilities located so as to allow the
prompt assessment and care of ill travellers, and (ii) adequate staff, equipment and premises;(b) to provide access to equipment and personnel for the transport of ill travellers to an
appropriate medical facility; (c) to provide assessment of and care for affected travellers by
establishing arrangements with local medical facilities for their isolation, treatment and othersupport services that may be required; (d) to provide appropriate space, separate from othertravellers, to interview suspect or affected persons; (e) to provide for the assessment and, if
required, quarantine of suspect travellers, preferably in facilities away from the point of entry.
5.1.3. Cleaning, disinfection and waste management
Ship owners, crew managers and other ship operators (or their representatives) should ensurethat the following measures are strictly followed as soon as a confirmed COVID-19 case has
been disembarked from the vessel, with the cabin or quarter facilities where they wereisolated/managed to be thoroughly cleaned and disinfected.
Box 4: Essential instructions for cleaning, disinfection and waste management
Information and instructions for cleaning, disinfection and waste management
If a COVID-19 event takes place on board the vessel, protocols for cleaning and disinfection should be carriedout by personnel trained to clean surfaces contaminated with infectious agents.
Seafarers should further be routinely informed and instructed in handling laundry, food service utensils andwaste from cabins of possible cases and contacts as infectious, in accordance with procedures for handlinginfectious materials available on board.

14

Further resources on cleaning and disinfection of ships can be found from ECDC19 and EU HEALTHYGATEWAYS20 and WHO7.

5.1.4. Management of contacts
Ship owners, crew managers and other ship operators (or their representatives) should ensurethat following a confirmed COVID-19 case, the below procedures are implemented:• Testing all contacts of a confirmed case by NAAT (e.g. RT-PCR if available on board) or by
RADT.
• If contacts test positive, they should be immediately isolated as described in Section 5.1.
• Place contacts in quarantine in accordance with Table 1.
The suggested measures for work restrictions, isolation and quarantine must always be
considered in accordance with any national/local regulations that apply.
Box 5: Essential information regarding COVID-19 contact management
Information regarding management of COVID-19 contacts
In all situations ship owners, crew managers and other ship operators (or their representatives) should
inform:• Seafarers that when undergoing work restrictions, they should follow strict measures as described in Table
2.
• Local public health authorities in the event that any form of quarantine is taking place in their local
region/district in accordance with national/local regulations.

A flow chart illustrating the response to a COVID-19 event on board a commercial vessel can befound in Annex 3.

5.2 Overview of general measures to mitigate COVID-19
transmission and considerations for the seafarer’s journey
Seafarers can observe personal protective measures to mitigate transmission, both on board
and during their journey to and from the vessel. Furthermore, ship owners, crew managers andother ship operators (or their representatives) can also facilitate measures during each stage ofthe seafarers’ journey.
Table 2 outlines general measures for avoiding transmission that ship owners should inform andsupport seafarers to comply with, regardless of where public health observation takes place(ashore prior to embarkation or on board at the start of work duties) and seafarers’ vaccination
status.
Table 3 presents considerations for ship owners, crew managers and other ship operators (ortheir representatives) during specific stages of the seafarers’ journey to reach the commercial
vessel and repatriate (including their time on board).

15

Table 2: Overview of general personal protective measures to limit COVID-19 transmission
General measures to
Examples for ship owners to facilitate measures
minimize transmission risk
Minimizing interaction between
seafarers

Use of face masks to prevent
droplet transmission• Ensure any documentation required by seafarers for the purpose of crew changes is provided to them through electronic means to avoid non-essential
contact with other individuals (if possible).
• When feasible, arrange for seafarers to travel (joining the ship or returning home) individually or in cohorts (e.g. up to five seafarers per cohort). Ensure whenarranging transport or designated accommodation for public health observation, that cohorts do not change throughout the journey and that there is nointeraction between cohorts (as far as practicable).
• Ensure availability of face masks for the seafarers’ journey to/from the commercial vessel and while on board.
- Respirators (e.g. FFP2 standard or equivalent) as a first priority when available for use by the public and if sufficient supplies are available after
prioritization for use in healthcare settings.
- Medical face masks when respirators are not available (where strategies to improve fit ‡‡ could be considered)• Provide guidance and periodic/regular instruction to seafarers related to use of face masks (and other PPE where needed) including:- Settings and situations when face mask use and PPE is required.
- Information on procedures and best practices for wearing (donning), removal (doffing), management and safe disposal or storage of face masks and other

PPE.
- Reminding seafarers that any face mask use is complementary to other personal protective measures such as physical distancing, hand hygiene,
respiratory etiquette and avoiding touching one’s eyes/nose/mouth.
More detailed resources can be found from WHO21,22, ECDC23 and EU HEALTHY GATEWAYS12.
• Ensure availability of hand hygiene materials for the seafarers’ journey to/from the commercial vessel (where applicable) and while on board:
Hand hygiene

Respiratory etiquette∞- Soap and water- Alcohol-based hand rub solution (containing at least 60% ethanol or 70% isopropanol)• Provide guidance and periodic/regular instruction to seafarers related proper hand hygiene including:- Hand washing techniques- When hand rubbing with an alcohol-based solution can be used, instead of hand washing and how this can be performed
More detailed resources can be found from WHO18 and ECDC23.
• Ensure availability of respiratory etiquette supplies for the seafarers’ journey to/from the commercial vessel (where applicable) and while on board:- Disposable tissues, no-touch waste bins
• Provide guidance and periodic/regular instruction to seafarers related to proper respiratory etiquette.

If there is limited availability of respirators, their use should be prioritized considering:- Setting and job position: prioritized for health care workers, medical personnel or those providing direct care to a possible or confirmed COVID-19 case, especially if aerosol-generating procedures are performed- Vulnerability of wearer: use of respirators if could be prioritized for seafarers belonging to high-risk groups for severe COVID-19 complications or those that have not been vaccinatedStrategies to improve mask fit include using masks with nose wires, using mask fitters/braces, using a knotting/tucking technique or double masking. Further details about strategies that can be used to improve face mask fit
can be found from ECDC (https://www.ecdc.europa.eu/en/publications-data/using-face-masks-community-reducing-covid-19-transmission) and the Centers for Disease Control and Prevention(https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html)‡‡

16

Table 3: Measures for consideration during seafarer journey

Phase of seafarer
journey

Situation

Options for consideration by ship owners, crew managers and other ship operators (or their representatives)
Ensure transit of seafarers conducted in controlled way by:•

Arranging private transport for seafarers and informing seafarers to avoid use of public transport as far aspracticable•

Ensuring the private transport vehicle arrives early to meet the seafarer, to limit the seafarer’s interaction withothers that may occur if they wait for their transport to arrive•

Ensuring proper cleaning and disinfection protocols are carried out between each use of a private transport
vehicle in accordance with WHO24 and ECDC technical guidance for cleaning and disinfection of non-health caresettings19•

Ensuring that alcohol-based hand rub and face masks are available to the seafarer in the private transport vehicle(and means to dispose of face masks, e.g. secured plastic bag).

••

Informing seafarers to wear face masks for the entire duration of the transit•

Ensuring measures to limit interaction between seafarers and maintain physical distancing as far as practicablewithin means of transport:- Arranging so seafarers travel individually in private transport vehicle (if feasible) or arranging seafarers’
transit in cohorts•

Informing seafarers travelling by aircraft to comply with the airline and aircraft protocols related to personal
protective and hygiene measures implemented on board. If such protocols are not in place, ship owners could
inform seafarers to adhere to a minimum standard of personal protective and hygiene measures when in
airports and on aircrafts (e.g. in accordance with guidance from IMO25, ICAO26 and ECDC/EASA27)

When transiting in means of transport§§• Travel to/from designated public
Travelling to join thecommercial vessel orreturn to place of origin

health observation facility (e.g. hotel)• Travel to and from airport in countryof origin or destination country• Travel to and from the seaport indestination country• Travel on an aircraft

When at transport hub
At transport hubs

• Airports/seaports waiting to embark
an aircraft/commercial vessel

Informing seafarers that any personal baggage should be carried by seafarers themselves as much as possible at
all times while within the transfer vehicle)

Inform seafarers to:• Keep physical distancing at all times while in transport hubs, minimizing close contact with others and avoiding theuse of public areas in the hub, such as eating establishments

As seen in Annex 2 several points of transit occur in means of transport throughout the seafarers’ journey (In accordance with the Industry recommended framework of protocols for ensuring safe ship crew changes and travel
during the coronavirus (COVID-19) pandemic presented in IMO MSC.1/Circ.1636/Rev.1. 22 April 2021 (https://wwwcdn.imo.org/localresources/en/MediaCentre/HotTopics/Documents/MSC%201636%20protocols/MSC.1Circ.1636%20-%20Industry%20Recommended%20Framework%20Of%20Protocols%20For%20Ensuring%20Safe%20Ship%20Crew%20Changes%20And%20Travel.pdf)
§§

17

•

At seaport

During screening /embarkation/
disembarkation
When no interaction between seafarers
or others• While in individual cabins
When exiting/outside of individual
cabins and interaction among seafarers
occurs• During work activities• Gathering in mess halls, laundry andPractice thorough and frequent hand hygiene, respiratory etiquette, and use of a face mask (in accordance withnational/local regulations)

Inform seafarers to:•
Keep physical distancing•
Use face masks•
Practice hand hygiene and respiratory etiquette•
Ensure safe disposal of disposable PPE used during travel, handling their own luggage 25
Inform seafarers that:• Face masks are not needed• Frequent and thorough hand hygiene and respiratory etiquette should be practiced
Ensure general measures to avoid transmission on board are taken:• Consider increasing frequency of meal service to limit crowding• Consider staggering seafarers’ work shifts to limit crowding during work activities

recreational areas***On board commercial
vesselWhen external visitors (shore-side
personnel, inspectors etc.) board thevessel †††Inform seafarers that in these situations strict personal protective and hygiene measures should be followed:• Maintaining as far as practicable 1.5 metre physical distance• Use of a face mask at all times• Practice frequent/thorough hand hygiene and respiratory etiquette
Inform seafarers that in these situations strict personal protective and hygiene measures should be followed for theduration of quarantine:

When seafarers undergo public healthobservation period•

Avoiding as much as possible non-essential contact with others and use of shared areas on board the ship
(mess halls, laundry rooms etc.)•

Limiting interaction with other seafarers during work activities (assign to positions where work alone) or
ensure strict measures (physical distancing of 1.5 metres and use of face mask when working with others)•••

Wearing a face mask at all times when outside of individual cabin
Practicing frequent/thorough hand hygiene and respiratory etiquette
Remaining in individual cabins when not working as much as possible*** If during quarantine the conditions on board are not suitable to mitigate the risk of transmission, it could be considered to close common areas such as laundry rooms/mess halls/recreational areas.
††† Only the minimum number of personnel required should be allowed to board in order to limit interactions between seafarers and shore-based personnel.

18

•
•
•

Eating meals in their cabin (if possible)
Not entering galley areas of the vessels

Transiting the vessel through outer walkways when possible
Ensure that:• Only those individuals necessary enter the isolation area (ideally the same person)• Appropriate PPE is available to those entering isolation area and they are trained in its use (wearing, removing,safe disposal):
Areas possibly contaminated on board
commercial vessel• While providing care in medical facility
where possible COVID-19 case isolatedon board••••

Properly fitting respirator (FFP2) or if unavailable medical face masks
Eye protection (goggles or face shield)
Disposable gloves
Long-sleeved impermeable gown

• Individuals practice frequent and thorough hand hygiene• Isolation areas on board are cleaned and disinfected in accordance with WHO24, ECDC19 and EU HEALTHYGATEWAYS20 technical guidance• Items such as laundry, food service utensils and waste from the medical facility where possible cases are in
isolation should be handled as infectious

196. Public health measures during shore-side visit
Like for every other citizen, seafarers can enjoy their right to shore leave subject to strict respectof any public health measures applicable to the local population and following all precautionary
measures to minimise the risk of infection coming on board. Shore leave and shore-side visits at a
port of call should only be possible under specific circumstances. A risk assessment could be
conducted to ensure shore leave is safe and appropriate. Issues to consider include the need tominimise the risk of infection coming on board, balanced against the benefits to a seafarer’s
physical and mental wellbeing of being allowed ashore.
When seafarers are able to safely take shore-side visits at a port of call, ship owners, crew
managers and ship operators (or their representatives) should support seafarers to comply withstrict public health measures while shore-side. It could be considered to advise seafarers to visit
an ICMA run seafarers’ centre in the port which is observing and applying COVID-19 prevention
measures protocols, to avoid the seafarers being exposed with local populations.
Box 6: Essential information for seafarers regarding shore-side visits
Information for seafarers
Seafarers should receive written guidance, instructions and material in English and if possible in theirnational language from ship owners, crew managers and ship operators (or their representatives) for the
purposes of shore-side visits with information about:• Any national/local public health requirements or measures in place for the local population at the port ofcall.
• General personal protective and hygiene measures (as outlined in Table 2) to protect themselves and the
local population against COVID-19.
Furthermore, they should:• Facilitate seafarer’s compliance with requirements during shore-side visits by providing any necessary
supplies (e.g. face masks, alcohol-based hand rub) for seafarers’ shore-side visit.

7. Journey from the ship to home
Ship owners, crew managers and ship operators (or their representatives) should facilitate thedisembarkation process to allow seafarers to follow all personal protective and hygiene measureswhile disembarking, including maintaining physical distancing from other persons while
disembarking, providing the appropriate PPE, ensuring safe disposal of disposable PPE used during
travel, and handling their own luggage25.
Seafarers that will disembark the ships and will be travelling to their country of origin could be
subject to undergo a quarantine period and testing and or vaccination requirements as pernational/local requirements in their destination country/origin country.

8. Considerations for crew vaccinations
WHO reported that seafarers gaining access to vaccination continues to be challenging for thisgroup7. Furthermore, WHO recommends to Member States to allow entry/exit from the country
without requiring proof of COVID-19 vaccination. Prevention and control strategies on board ships
should not rely exclusively on vaccination. As indicated by WHO, “fully vaccinated people havesome level of protection against COVID-19, and are less likely to infect someone else. However,20

vaccines do not confer 100% immunity, nor they prevent transmitting the virus to others, andbreakthrough infections may occur”.
It is recommended that all seafarers have access to vaccination against COVID-19. Currently,
seafarers may be vaccinated in accordance with their national vaccination programme, and somecountries are developing vaccination programmes specifically targeting seafarers. As
transportation workers, seafarers are recommended to be considered a priority group by EU/EEA
MS for vaccination against COVID-19 in accordance with the European Commission
Communication28.
Vaccination of crew should be legally acquired from official sources. Moreover, all vaccinated crew
members should hold valid proof of vaccination if applicable based on national requirements, andinform their employer about their vaccination status (Annex 4 provides a list of information to be
included in the valid proof of vaccination particularly for the purposes of validating thevaccination). The vaccine delivered should be included in the list of approved vaccines by aninternationally recognized authority (EMA and/or WHO) as described in the definitions section ofthis document.
ECDC indicates in its options for response to the EU MS: “National Immunisation TechnicalAdvisory Groups (NITAGs) in EU/EEA countries should consider a booster dose for those 40 years
and over, targeting the most vulnerable and the elderly. Countries could also consider a booster
dose for all adults 18 years and older at least six months after completion of the primary series toincrease protection against infection due to waning immunity, which could potentially reducetransmission in the population and prevent additional hospitalisations and death”.
The European Commission press release of 21 December indicates: “Vaccination certificates will
be accepted by Member States for a period of nine months since the administration of the last doseof the primary vaccination. For a single-dose vaccine, this means 270 days from the first and only
shot. For a two-dose vaccine it means 270 days from the second shot, or, in line with thevaccination strategy of the Member State of vaccination, the first and only shot after having
recovered from the virus. Under these new EU rules for intra-EU travel, Member States must accept
any vaccination certificate that has been issued less than nine months since the administration of
the last dose of the primary vaccination. Member States are not able to provide for a shorter nor
for a longer acceptance period”. Exceptions apply for persons under the age of 18 ‡‡‡.
Records of crew members who have received vaccination, including names and dates, should be
kept in order to support decision making regarding public health measures during a potential
outbreak situation. Proof of vaccination/vaccination documentation should be kept by seafarers’
themselves so it can be shown when required. Any data kept by the ship owners, crew managers
and ship operators (or their representatives) should be handled in accordance with the relevant
legislation for personal data protection.

Certificates held by persons aged 18 and above indicating the completion of the primary vaccination series shall be
accepted only if not more than 270 days have passed since the date of the latest dose in that series‡‡‡

21Box 7: Essential information for seafarers regarding vaccination
Information for seafarers
Seafarers should receive existing written guidance, instructions and material in English and if possible in theirnational language from ship owners, crew managers and other ship operators (or their representatives)
regarding COVID-19 vaccination to promote its use. This can include information regarding:• Benefits of vaccination to protect seafarers’ health• Types of vaccines available• Vaccine safety and possible side-effects• Locations where seafarers could be vaccinated, if known and/or facilitated by ship owners, crew managers
or ship operators (or their representatives). A list of countries that have implemented seafarer vaccination
programs, or have signalled their intent to do so, in designated ports within there is provided at thefollowing link: https://icma.as/vaccines/
Information about COVID-19 vaccines and vaccine safety can be found from:• EMA: COVID-19 vaccines29• ECDC: Questions and answers on COVID-19: Vaccines30• WHO: Coronavirus disease (COVID-19): Vaccines31 and Vaccines safety32• International Chamber of Shipping (ICS)• Coronavirus (COVID-19): Roadmap for Vaccination of International Seafarers33, Vaccination for Seafarers andShipping Companies: A Practical Guide34, Legal, Liability and Insurance Issues arising from Vaccination of
Seafarers35• Additional guidance from ICS can be found at the following link: https://www.ics-shipping.org/supportingshipping/covid/

9. Supporting seafarer welfare and safeguarding
mental and physical health9.1. Seafarer access to health care
In the context of the COVID-19 pandemic and measures implemented by Member States to limit
the spread of the virus, seafarers have faced difficulties accessing medical care (for both COVID19 and other conditions) on shore36.
Ship owners, crew managers and other ship operators (or their representatives) should ensurethat the commercial vessel’s written contingency plan/outbreak management plan includes:• Communication plans and routes in place to facilitate rapid communication between thevessel and the maritime telemedicine assistance service (TMAS) and/or alternative shorebased healthcare services which should be pre-defined in the contingency plan/outbreakmanagement plan.
• Criteria to decide if a possible COVID-19 case can be managed on board or immediate medicalcare is required7.
• Plan for seafarers responsible to provide medical care on board the vessel, to ensure they
are adequately instructed in procedures for deciding if a seafarer requires immediate
assistance for COVID-19 or other non-related health condition, or if medical care can beprovided when the ship reaches the next port of call (radio medical advice could beconsidered).

22

9.2 Seafarer access to psychological assistance and mental healthservices
Stressors linked to the COVID-19 pandemic can include challenges related to disembarkation
and repatriation, restricted access to medical care on shore, lack of information about COVID19 prevention and control measures on board, among other issues. These factors further
contribute to the adverse psychosocial health of seafarers leading to stress, fatigue, feelingsof social isolation and other conditions such as anxiety and depression7,37.
Risk communication messaging should take into consideration language and culturaldifferences of seafarers. In addition to English and where possible, messaging should beavailable in national languages.
To support seafarers’ mental wellbeing during the COVID-19 pandemic, ship owners, crew
managers and other ship operators (or their representatives) should ensure:• Seafarers have access to confidential mental health/psychosocial services at all times
in English and where possible in national languages. If in person services are notfeasible, remotely offered services should be available through online/video tools or
telephone services (e.g. telemedicine). Several helplines exist to support seafarers
and provide mental health assistance; a list of available helplines is available fromICS§§§.
• Orientation and courses on mental health awareness and healthy ways of coping withstress. Resources and guidance for seafarers to support mental wellbeing and manage
stress are available from the International Seafarers’ Welfare and Assistance
Network**** (ISWAN) and ICS††††.
• Seafarer communication with family/friends and access to entertainment on board isfacilitated (e.g. via offering internet for seafarers’ personal use free of charge).
• Plans and procedures are in place to manage and mitigate seafarer fatigue(particularly during COVID-19) in line with IMO guidelines on fatigue38.
Box 8: Essential information to seafarers related to mental health services

Information to seafarers
Ship owners, crew managers and ship operators (or their representatives) should inform and provide
continuous up-to-date information to seafarers (through guidance, instructions and material in English and if
possible in their national language) about:• Resources available to them for mental health/psychosocial support (prior to embarkation or atembarkation).
• Crew change processes and repatriation, national/local regulations and public health measures
implemented at ports of call, the epidemiological situation at the ports of call, information related to
COVID-19 prevention and control.

WHO provides information on resources available to support seafarer mental health7 and guidance on
mental health/psychosocial considerations during COVID-1939.

https://www.ics-shipping.org/wp-content/uploads/2021/06/Access-to-company-or-other-support-helplines-for-seafarers.pdf
https://www.seafarerswelfare.org/seafarer-health-information-programme/good-mental-health†††† https://www.ics-shipping.org/publication/handling-a-mental-health-crisis-or-emergency-and-spotting-suicidal-behaviour-in-seafarers/
§§§

****

23

10. Annexes
Annex 1: Relevant European Commission Communications, Recommendations andGuidelines• Commission Delegated Regulation (EU) 2022/503 of 29 March 2022 amending Regulation (EU) 2021/953
of the European Parliament and of the Council as regards exempting minors from the acceptance periodof vaccination certificates issued in the EU Digital COVID Certificate format (Text with EEA relevance)
C/2022/2050. Available at: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32022R0503• Commission Delegated Regulation (EU) 2021/2288 of 21 December 2021 amending the Annex toRegulation (EU) 2021/953 of the European Parliament and of the Council as regards the acceptance periodof vaccination certificates issued in the EU Digital COVID Certificate format indicating the completion of
the primary vaccination series (Text with EEA relevance) C/2021/9920. 21 December 2021. Available at:https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32021R2288&qid=1643281793602• Commission Implementing Decision (EU) 2021/2301 of 21 December 2021 amending Implementing
Decision (EU) 2021/1073 laying down technical specifications and rules for the implementation of the trust
framework for the EU Digital COVID Certificate established by Regulation (EU) 2021/953 of the European
Parliament and of the Council (Text with EEA relevance). 21 December 2021. Available at: https://eurlex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32021D2301• REPORT FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL pursuant to Article
16(1) of Regulation (EU) 2021/953 of the European Parliament and of the Council on a framework for theissuance, verification and acceptance of interoperable COVID-19 vaccination, test and recovery certificates(EU Digital COVID Certificate) to facilitate free movement during the COVID-19 pandemic. Available at:https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:52021DC0649• COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE
EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS Addressing
together current and new COVID-19 challenges. Available at: https://eur-lex.europa.eu/legalcontent/EN/TXT/?uri=CELEX:52021DC0764• Regulation (EU) 2021/953 of the European Parliament and of the Council of 14 June 2021 on a framework
for the issuance, verification and acceptance of interoperable COVID-19 vaccination, test and recovery
certificates (EU Digital COVID Certificate) to facilitate free movement during the COVID-19 pandemic (Textwith EEA relevance). 14 June 2021. Available at: https://eur-lex.europa.eu/legalcontent/EN/TXT/?uri=CELEX:32021R0953• Regulation (EU) 2021/954 of the European Parliament and of the Council of 14 June 2021 on a framework
for the issuance, verification and acceptance of interoperable COVID-19 vaccination, test and recovery
certificates (EU Digital COVID Certificate) with regard to third-country nationals legally staying or residingin the territories of Member States during the COVID-19 pandemic (Text with EEA relevance). 14 June 2021.
Available at: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32021R0954• Council Recommendation (EU) 2021/1346 of 30 August 2021 amending Recommendation (EU) 2020/912
on the temporary restriction on non-essential travel into the EU and the possible lifting of such restriction.
31.08.2021. Available at: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=celex%3A32021H1346• Council Recommendation (EU) 2021/961 of 14 June 2021 amending Recommendation (EU) 2020/1475 ona coordinated approach to the restriction of free movement in response to the COVID-19 pandemic.
16.06.2021. Available at: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32021H0961• Proposal for a COUNCIL RECOMMENDATION amending Council Recommendation (EU) 2020/1475 of 13
October 2020 on a coordinated approach to the restriction of free movement in response to the COVID-19
pandemic.
31.05.2021.
Availableat:https://eur-lex.europa.eu/legalcontent/en/TXT/?uri=CELEX%3A52021DC0294

24

• Communication from the Commission to the European Parliament, the European Council and the Council:
A common path to safe and sustained re-opening COM/2021/129 final. 17.03.2021. Available at:https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A52021DC0129• Communication from the Commission to the European Parliament, the European Council and the Council:
A united front to beat COVID-19 COM/2021/35 final. 19.01.2021. Available at: https://eurlex.europa.eu/legal-content/EN/TXT/?uri=CELEX:52021DC0035• Commission Recommendation of 22.12.2020 on a coordinated approach to travel and transport in
response to the SARS-COV-2 variant observed in the United Kingdom. 28.12.2020. Available at: https://eurlex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32020H2243• Communication from the Commission to the European Parliament, the European Council and the Council
on additional COVID-19 response measures. 28.10.2020. Available at: https://eur-lex.europa.eu/legalcontent/GA/TXT/?uri=CELEX:52020DC0687• Communication from the Commission to the European Parliament and the Council: Preparedness for
COVID-19 vaccination strategies and vaccine deployment COM/2020/680 final. 15.10.2020. Available at:https://eur-lex.europa.eu/legal-content/GA/TXT/?uri=CELEX:52020DC0680• Communication from the Commission: Guidelines on the progressive restoration of transport services andconnectivity – COVID-19 (2020/C 169/02), 15.05.2020. Available at: https://eur-lex.europa.eu/legalcontent/EN/ALL/?uri=CELEX:52020XC0515(04)• Communication from the Commission: Towards a phased and coordinated approach for restoring freedomof movement and lifting internal border controls — COVID-19 2020/C 169/03 C/2020/3250 OJ C 169.
15.05.2020. Available at: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:52020XC0515(05)• Communication from the Commission to the European Parliament, the Council, the European Economic
and Social Committee and the Committee of the Regions Tourism and Transport in 2020 and Beyond
COM/2020/550
final.
13.05.2020.
Availableat:https://eur-lex.europa.eu/legalcontent/EN/TXT/?qid=1591191111789&uri=CELEX:52020DC0550• Communication from the Commission Guidelines on protection of health, repatriation and travel
arrangements for seafarers, passengers and other persons on board ships 2020/C 119/01. 14.04.2020.
Availableat:https://eur-lex.europa.eu/legalcontent/EN/TXT/?qid=1587132931038&uri=CELEX%3A52020XC0414%2801%29• Communication from the Commission: Guidelines concerning the exercise of the free movement of workers
during COVID-19 outbreak (2020/C 102 I/03). 30.03.2020 Available at: https://eur-lex.europa.eu/legalcontent/EN/TXT/?uri=CELEX%3A52020XC0330%2803%29• Communication from the Commission COVID-19 Guidance on the implementation of the temporary
restriction on non-essential travel to the EU, on the facilitation of transit arrangements for the repatriationof EU citizens, and on the effects on visa policy 2020/C 102 I/02 C/2020/2050 OJ C 102I. 30.03.2020.
Availableat:https://eur-lex.europa.eu/legalcontent/EN/TXT/?qid=1585642173770&uri=CELEX:52020XC0330(02)• Communication from the Commission on the implementation of the Green Lanes under the Guidelines forborder management measures to protect health and ensure the availability of goods and essential services(2020/C
96I/01).
24.03.2020.
Availableat:https://eur-lex.europa.eu/legalcontent/EN/TXT/?uri=CELEX%3A52020XC0324%2801%29• Communication from the Commission to the European Parliament, the European Council and the Council:
COVID-19: Temporary Restriction on Non-Essential Travel to the EU. 16.03.2020. Available at: https://eurlex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A52020DC0115• Covid-19 Guidelines for border management measures to protect health and ensure the availability ofgoods and essential services 2020/C 86 I/01 OJ C 86I. 16.03.2020. Available at: https://eurlex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A52020XC0316%2803%29

25

Annex 2: Representation of IMO Recommended Framework of Protocols for ensuring safe
ship crew changes and travel

Source: https://www.ics-shipping.org/publication/covid-19-12-step-guide-to-the-imos-recommendedframework-of-protocols-for-ensuring-safe-ship-crew-changes-and-travel/

26

Annex 3: Response to a COVID-19 event on board

27

Annex 4: Information to be included in seafarers' valid proof of vaccination
A valid Digital COVID-19 Certificate (DCC)‡‡‡‡ or other certificate/document could include the following
information:(a) name: surname(s) and forename(s);(b) date of birth;(c) disease or agent targeted (SARS-CoV-2 or one of its variants);(d) vaccine/prophylaxis;(e) vaccine product name;(f) vaccine marketing authorization holder or manufacturer;(g) number in a series of vaccinations/doses and overall number of doses in the series;(h) date of vaccination, indicating the date of the latest dose received §§§§;(i) country of vaccination;(j) certificate issuer;(k) a unique certificate identifier or other means to validate the vaccination such as contact
information in order to communicate with the healthcare provider or clinic site that issued thecertificate, or the vaccination registry site.

https://ec.europa.eu/info/live-work-travel-eu/coronavirus-response/safe-covid-19-vaccineseuropeans/eu-digital-covid-certificate_en§§§§ certificates held by persons aged 18 and above indicating the completion of the primary vaccination series
shall be accepted only if not more than 270 days have passed since the date of the latest dose in that series
‡‡‡‡

28

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31

Working group
Barbara Mouchtouri1, Lemonia Anagnostopoulos1, Leonidas Kourentis1, Martin Dirksen-Fischer2,
Kristina Militzer3, Jan Heidrich3, Mauro Dionisio4, Miguel Dávila-Cornejo5, Iratxe Moreno5, JoséFrancisco Gallegos6 and Christos Hadjichristodoulou1
1. Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly,
Larissa, Greece
2. Institute for Hygiene and Environment of the Hamburg State Department for Health andConsumer Protection, Hamburg, Germany
3. Institute for Occupational and Maritime Medicine, University Medical Center HamburgEppendorf, Germany
4. Italian Ministry of Health, Rome, Italy
5. Ministry of Health, Madrid, Spain
6. Port of Algeciras, Spain

32

COVID-19 Weekly Epidemiological Update
Edition 101 published 20 July 2022
In this edition:• Global overview• Special Focus: Update on SARS-CoV-2 variants of interest and variants of concern• WHO regional overviews

Global overview
Data as of 17 July 2022
Globally, during the week of 11 to 17 July 2022, the number of weekly cases plateaued, with just under 6.3
million new cases after an increasing trend for the past five weeks (Figure 1). The reported number of new
weekly deaths is increasing with 11 000 fatalities reported.
At the regional level, the number of new weekly cases increased in the Western Pacific Region (+37%), theRegion of the Americas (+9%) and the South-East Asia Region (+5%), while it decreased in the African Region(-27%) and the European Region (-16%). The number of new weekly cases in the Eastern Mediterranean Region
was similar to the figure reported during the previous week. The number of new weekly deaths increased in theSouth-East Asia Region (+20%), the Eastern Mediterranean Region (+15%) and the Region of the Americas (+7%),
while it decreased in the African Region (-39%) and the European Region (-14%). The number of new weekly
deaths in the Western Pacific Region was similar to the figure reported during the previous week.
As of 17 July 2022, over 559 million confirmed cases and over 6.3 million deaths have been reported globally.
Current trends in reported COVID-19 cases and deaths should be interpreted with caution as several countries
have been progressively changing COVID-19 testing strategies, resulting in lower overall numbers of tests
performed and consequently lower numbers of cases detected. Additionally, data is continuously updated toincorporate regular changes made by countries retrospectively.
Figure 1. COVID-19 cases reported weekly by WHO Region, and global deaths, as of 17 July 2022**

20 000 000

Cases

15 000 000

120 000

AmericasSouth-East Asia
EuropeEastern Mediterranean
AfricaWestern Pacific

100 000
80 00060 000

10 000 000

40 0005 000 000

20 000030-Dec20-Jan10-Feb02-Mar23-Mar
13-Apr04-May25-May15-Jun06-Jul
27-Jul17-Aug07-Sep28-Sep19-Oct
09-Nov
30-Nov
21-Dec11-Jan01-Feb
22-Feb15-Mar
05-Apr
26-Apr17-May07-Jun28-Jun19-Jul
09-Aug30-Aug20-Sep11-Oct01-Nov
22-Nov
13-Dec03-Jan24-Jan14-Feb07-Mar28-Mar
18-Apr
09-May30-May20-Jun11-Jul0

Reported week commencing**See Annex 1: Data, table, and figure notes
1

Deaths

25 000 000

At the country level, the highest numbers of new weekly cases were reported from the United States of America(866 479 new cases; +18%), France (757 830 new cases; -15%), Italy (718 925 new cases; +9%), Germany (602930 new cases; -3%), and Japan (559 111 new cases; +107%). The highest numbers of new weekly deaths werereported from the United States of America (2345 new deaths; +5%), Brazil (1 751 new deaths; +7%), Italy (784
new deaths; +37%), Spain (610 new deaths; -1%), and China (576 new deaths; -17%).
Table 1. Newly reported and cumulative COVID-19 confirmed cases and deaths, by WHO Region, as of 17 July 2022**

WHO Region

New cases
in last 7
days (%)

Change in
new cases
in last 7
days *

Cumulative
cases (%)

New deaths inlast 7 days (%)

Change in new
deaths in last 7days *

Cumulative
deaths (%)

Europe2 785 259
(44%)

-16%

235 432 245
(42%)

3 311
(30%)

-14%

2 036 904
(32%)

Americas1 756 694
(28%)

9%

167 081 979
(30%)

5 470
(50%)

7%

2 775 646
(44%)

Western Pacific

1 444 382
(23%)

37%

66 933 896
(12%)

1 366
(12%)

-3%

241 684(4%)

South-East Asia

173 854(3%)

5%

58 967 419
(11%)

538
(5%)

20%

791 164(12%)

Eastern
Mediterranean

120 859(2%)-1%

22 288 922
(4%)

228
(2%)

15%

344 024(5%)

Africa15 409(<1%)-27%

9 175 098
(2%)

87
(1%)

-39%

173 861(3%)

Global

6 296 457
(100%)

0%559 880 323(100%)

11 000(100%)-1%

6 363 296
(100%)*Percent change in the number of newly confirmed cases/deaths in the past seven days, compared to seven days prior**See Annex 1: Data, table, and figure notes

For the latest data and other updates on COVID-19, please see:• WHO COVID-19 Dashboard• WHO COVID-19 Weekly Operational Update and previous editions of the Weekly Epidemiological Update• WHO COVID-19 detailed surveillance data dashboard

2

Figure 2. COVID-19 cases per 100 000 population reported by countries, territories and areas, 11 - 17 July 2022***See Annex 1: Data, table, and figure notes3Figure 3. COVID-19 deaths per 100 000 population reported by countries, territories and areas, 11 - 17 July 2022****See Annex 1: Data, table, and figure notes
4Special Focus: Update on SARS-CoV-2 variants of interest and variants of concern
Geographic spread and prevalence of VOCs
Globally, from 13 June to 13 July 2022, 200 845 SARS-CoV-2 sequences were collected and submitted to GISAID.
Among these sequences, the Omicron VOC remains the dominant variant circulating globally, accounting for 95.4%(191 648) of sequences. The remaining 4.4% (8876) sequences are awaiting PANGO lineage designations and 0.2%(321) are Delta and several recombinants.
Among Omicron sequences, as of epidemiological week 27 (4 to 10 July 2022), BA.2 represents 2.61%, while
BA.2.12.1 represents 4.51%, BA.4 represents 10.57%, and BA.5 represents 53.59%. Comparing to the proportion of
Omicron sequences collected during epidemiological weeks 26 (27 June to 3 July), BA.2 declined from 3.84% to2.61%, BA.2.12.1 declined from 10.59% to 4.51%, BA.4 declined from 13.21% to 10.57% while BA.5 increased from51.84% to 53.59%. Based on the data downloaded from GISAID on 18 July 2022, BA.5 has been reported in 100
countries and continues to drive an increase in cases, hospitalisations and ICU admissions.
Several subvariants of Omicron have emerged and some of these are being monitored by WHOi. BA.2.75 is an
Omicron subvariant under monitoring, with earliest sequences reported from May 2022. BA.2.75 has nine additional
mutations in the spike compared to BA.2. There is no evidence yet of the extent to which these mutations impact ontransmissibility and disease severity compared to other circulating lineages. As of 18 July, 250 sequences of BA.2.75
from 15 countries have been reported on GISAID.
Current trends describing the circulation of Omicron subvariants should be interpreted with due consideration of thelimitations of SARS-CoV-2 surveillance systems, including differences in sequencing capacity and sampling strategies
between countries, as well as changes in sampling strategies and reductions in testing and sequences being
conducted and shared from countries around the world.
For more information on the assessment of SARS-CoV-2 variants and the WHO classification refer to Annex 2.

i

WHO tracking SARS-CoV-2 Variants

5Figure 4. Panel A and B: The number and percentage of SARS-CoV-2 sequences, as of 18 July 2022

Figure 4 Panel A shows the number and Panel B the percentage of all circulating variants since 1 April 2022. Omicron sister-lineages and additional
Omicron VOC descendent lineages under further monitoring (VOC-VUM) are shown. BA.1.X and BA.2.X include all BA.1 and BA.2 pooled descendent
lineages, except those already shown in the figure above. Source: SARS-CoV-2 sequence data and metadata from GISAID, as of 18 July 202

6

Table 2. Relative proportions of SARS-CoV-2 sequences over the last four weeks by specimen collection dateA.
Last 4 weeks by collection date (%) b
Countries

Sequencesa

2022-242022-252022-262022-27BA.1

177

482 065

0.01

0.01

0.01

0.00

BA.1.1

183

997 165

0.05

0.02

0.02

0.02

BA.1.X*179

899 907

0.04

0.03

0.02

0.01

BA.2

153

1 141 038

9.83

6.61

3.84

2.61

BA.2.11

23

815

0.02

0.02

0.00

0.01

BA.2.12.1

95

225 356

22.86

15.83

10.59

4.51

BA.2.13

48

3 737

0.32

0.21

0.14

0.12

BA.2.38

56

6 533

0.89

0.51

0.22

0.16

BA.2.75

15

250

0.09

0.14

0.08

0.05

BA.2.9.1

16

767

0.01

0.00

0.01

0.00

BA.2.X*147

547 294

9.14

6.05

3.19

2.39

BA.3

42

1 146

0.05

0.02

0.01

0.01

BA.4

88

49 813

11.47

12.15

13.21

10.57

BA.5

100

139 680

34.67

45.07

51.84

53.59

Delta#

203

4 362 456

0.01

0.04

0.01

0.00

OtherC210

2 776 891

10.54

13.30

16.82

25.95

Lineagea Data source: sequences and metadata from GISAID, data published on 18 July 2022.
b Relative proportions in %.

* BA.1.X and BA.2.X include all BA.1 and BA.2 pooled descendent lineages, except those already shown in the table above.
# Previously circulating VOC.
c Other includes all omicron lineages which are not listed in the table above as well as sequences which are awaiting PANGO lineage designations(presumed Omicron).

7

Table 3. Summary of phenotypic characteristics* of the Omicron VOC
Omicron (B.1.1.529)

Public health domainof impact
Transmissibility

Growth advantage and increased transmissibility
compared to Delta ii

Omicron sublineages
BA.1
Lower growth advantage compared
to BA.21, BA.4 and BA.5 2

Overall evidence suggests lower severity despite
No difference in disease severity
contrasting evidence. Earlier studies reported lower compared to BA.2, BA.4 and BA.5 13
severity compared to Delta. 3–7 However, more recent
studies in different settings reported similar 8,9 orincreased severity10 compared to Delta.3–7,11 12

BA.2
BA.4
Lower growth advantage
Growth advantage
compared to BA.4 and BA.5 1,2 compared to BA.2 2

Currently available Currently available
evidence does notevidence does not suggest
suggest a difference a difference in disease
Disease severity
in disease severity
severity compared to BA.2
compared to BA.2
and BA.413
13
and BA.5
Reduced risk of Omicron reinfection among individuals Reduced risk of reinfection with BA.1 Reduced risk of reinfection
Protection against
Protection against infection
previously infected with a different SARS-CoV-2
after infection with BA.215
following infection with BA.1 infection following
following previous BA.2
Risk of reinfection
15
variant compared to naïve individuals14,15
previous BA.2
infection 16
infection 16
Reduction in neutralizing activity reported as
Lower neutralising antibody titers
Lower neutralising antibody Lower neutralizing L
Impact on antibody compared to other VOCs17–19
compared to the index virus19
titers compared to the index antibody titres (7.6- Lower neutralising
responses
virus19fold) compared to
antibody titres (7.5-fold)BA.1 20,21
compared to BA.1 20,21
PCR assays that include multiple gene targets maintain S gene target failure
The majority will be S gene
S gene target
S gene target failure.
their accuracy to detect Omicron22; S gene target
target positive
failure.
Impacts on
failure/positivity (SGTF) may be a proxy for screening.
diagnostics
Limited to no impact on sensitivity of Ag-RDTs
observed23–26
No difference in the effectiveness of antiviral agents Reduced efficacy of cilgavimab32 and Reduced neutralising activity Reduced neutralising Reduced neutralising(polymerase and protease inhibitors) against thecasirivimab-imdevimab33
of sotrovimab, bamlanivimab, activity ofactivity of sotrovimab,
27
Omicron variant . Conserved neutralizing activity forcasirivimab, etesevimab,
sotrovimab,bamlanivimab, casirivimab,
three broadly neutralizing monoclonal antibodies
imdevimab and tixagevimab 34 bamlanivimab,
etesevimab, imdevimab(sotrovimab, S2X259 and S2H97) and a reduced
casirivimab,
and tixagevimab. Increased
Impact on treatment effectiveness of other monoclonal antibodies28–31
etesevimab,
resistance to cilgavimab
imdevimab andcompared to BA.234
tixagevimab.
Increased resistanceto cilgavimab
compared to BA.234
Impact on
Results of vaccine effectiveness (VE) studies should be interpreted with caution because estimates vary with the type of vaccine administered and the number of doses andvaccination
scheduling (sequential administration of different vaccines). For further information, see the section Interpretation of the results of the VE for the Omicron variantii Similar methodology used as Reference 1

8

No difference in disease
severity compared to BA.4
and BA.513

BA.5
Growth advantage
compared to BA.4 2

Figure 5. Vaccine effectiveness (VE) of primary series and first booster vaccination against the Omicron variant of concern

Dots represent point estimates of VE from each study; dark black horizontal lines represent median VE across all studies in stratum. All data is from a systematic review of COVID-19 VE studies; methods and summary tablesof VE studies can be found on view-hub.org. Vertical panels represent VE for full primary series (grey dots) and VE for homologous or heterologous booster vaccination (other colored dots) following completion of primaryseries vaccination with vaccine of primary series noted in panel header. All booster VE estimates are for first booster dose. Severe disease includes hospitalization, and pneumonia; symptomatic disease includes disease ofany severity level; any infection can include symptomatic and asymptomatic infection. Additional details on the methods for inclusion of the estimates in the plots are provided in text.

9Figure 5 summarises the impact of the Omicron variant on absolute vaccine effectiveness (VE) over time, grouped by the
primary series vaccine; booster doses may have been a different vaccine (i.e., both homologous and heterologous booster
vaccination VEs are shown). Additional information on vaccine performance against VOCs can also be found in Annex 3.
Since the last update, one new study (not yet peer reviewed) has been added to the figure. The study assessed the VE of
two and three doses of Pfizer BioNTech-Comirnaty against emergency department admissions and hospitalization due toOmicron BA.1 and BA.2 sub-lineages over time among adults 18 years and older in the United States of America.35
For more information on the methods for Figure 5 refer to Annex 4.
Interpretation of the results of absolute VE for the Omicron variant
To date, 34 studies from 14 countries (Argentina, Brazil, Canada, Chile, Czech Republic, Denmark, Finland, Norway,
Israel, Qatar, South Africa, the United Kingdom, the United States of America, and Zambia) have collectively assessed
the protection of six vaccines against the Omicron variant (12 studies contributed VE estimates of primary series
vaccination, four contributed to estimates of first booster vaccination only, and 18 contributed to both). Findings
from these studies show reduced VE of COVID-19 primary series vaccines against the Omicron variant for all
outcomes (severe disease, symptomatic disease, and infection) than has been observed for the other four VOCs.
Importantly though, VE estimates against the Omicron variant remain higher for severe disease than the otheroutcomes, in the majority of studies. The first booster vaccination substantially improves VE for all outcomes and for
all combinations of schedules with estimates available for both primary series and booster vaccination. VE declines
more with time after the first booster vaccination for symptomatic disease and infection than it does for severe
disease36; however, studies that assess VE of booster vaccination beyond six months to evaluate longer duration ofprotection are not yet available.
For severe disease, VE of the primary series showed little decline over six months. VE was ≥70% during the first threemonths after primary series vaccination for seven of 13 (54%) VE estimates for the mRNA vaccines (ModernaSpikevax and Pfizer BioNTech-Comirnaty). Of the two vector vaccines studies available, both had VE <70%: one
reported VE <70% for AstraZeneca-Vaxzevria and the other reported VE <50% for Janssen-Ad26.COV2.S. Four
estimates were available for inactivated vaccines: none of the three estimates for Sinovac-CoronaVac were ≥ 70%(two [67%] were ≥ 50%); the single estimate for Beijing CNBG-BBIBP-CorV (Sinopharm) was <70% but ≥50%. Beyond
three months after vaccination VE was ≥70% for 13 of 33 (39%) VE estimates for the mRNA vaccines (23 [70%] had
VE ≥50%); one of 13 (8%) AstraZeneca-Vaxzevria VE estimates was ≥70% (9 [69%] were ≥50%); neither of the two
estimates for the other vector-based vaccine, Janssen-Ad26.COV2.S, was ≥50%; the two VE estimates for SinovacCoronaVac were ≥50% but <70%.
The first booster dose vaccination improved VE against severe disease in all studies, and VE was ≥70% in 36 (95%) of
38 estimates evaluating VE between 14 days and three months of receipt of a booster dose (35 estimates evaluatedan mRNA booster, two evaluated a Janssen-Ad26.COV2.S booster, and one evaluated a Sinovac-CoronaVac booster);one Moderna-Spikevax booster dose had VE <50%, and one Janssen-Ad26.COV2.S booster dose had VE <70%. At
three to six months post mRNA booster, VE was ≥70% for 25 of 28 (89%) estimates (the primary series was an mRNA
vaccine in 19 of the 28 estimates, AstraZeneca-Vaxzevria in eight and Sinovac-CoronaVac in one). One study foundthe VE to be <70% but ≥50% following three to six months from the third dose of Sinovac-CoronaVac.

10

VE against symptomatic disease and infection within the first three months of primary series vaccination was lower
than against severe disease, and VE decreased more substantially over time. For symptomatic disease, only three of
14 (21%) VE estimates for the mRNA vaccines were ≥70% and only seven (50%) were ≥50%; one (25%) of the four VE
estimates for AstraZeneca-Vaxzevria was ≥70% while the remaining three estimates were <50%; the single estimate
for Janssen-Ad26.COV2.S was ≥70%, and both estimates for Sinovac (CoronaVac) were <50%. Beyond three months
after vaccination, only one of 35 (3%) VE estimates was ≥50% (25 estimates evaluated mRNA vaccines, eight
evaluated AstraZeneca-Vaxzevria, and two evaluated Sinovac-CoronaVac). mRNA booster vaccination after
completion of a primary series of an mRNA vaccine, AstraZeneca-Vaxzevria, or Sinovac-CoronaVac improved VE
against symptomatic disease: six of 23 (26%) VE estimates between 14 days and three months post booster were≥70% (18 [78%] were ≥50%); one (50%) of two VE estimates evaluating three doses of AstraZeneca-Vaxzevria was≥50% but <70%, as was the single estimate for three doses of Janssen-Ad26.COV2.S, and the single estimate for threedoses of Sinovac-CoronaVac was <50%. However, first booster dose protection declined rapidly over time: only fourof 15 (27%) estimates available at three to six months following receipt of an mRNA booster dose had VE ≥50% andnone were ≥70%. Neither the single estimate for three doses of AstraZeneca-Vaxzevria nor the single estimate forthree doses of Sinovac-CoronaVac assessed three to six months post booster vaccination was above 50%. VE against
infection showed a similar pattern of waning as that against symptomatic disease.

11WHO regional overviews:

Region of the Americas

Epidemiological week 11 - 17 July 2022**

African Region

The Region of the Americas reported over 1.7 million new cases, a 9%
increase as compared to the previous week. Eighteen of 56 (32%) countries
for which data are available reported increases in the number of new casesof 20% or greater, with the greatest proportional increases observed in Sint
Eustatius (69 vs 18 new cases; +283%), Peru (67194 vs 32889 new cases;+104%), and Saint Vincent and the Grenadines (114 vs 56 new cases; +104%).
The highest numbers of new cases were reported from the United States ofAmerica (866 479 new cases; 261.8 new cases per 100 000; +18%), Brazil (419273 new cases; 197.2 new cases per 100 000; +6%), and Mexico (141 241 newcases; 109.5 new cases per 100 000; -20%).

The African Region reported a decline in the number of new weekly cases,
with over 15 000 new cases reported, a 27% decrease as compared to theprevious week. Seven (14%) countries reported an increase in the number of
new cases of 20% or greater, with the greatest proportional increases seen in
Burundi (451 vs 169 new cases; +167%), Senegal (263 vs 133 new cases;+98%), and Eritrea (40 vs 23 new cases; +74%). The highest numbers of newcases were reported from Réunion (3599 new cases; 402 new cases per 100
000 population; +25%), South Africa (2482 new cases; 4.2 new cases per 100000; +25%), and Zambia (1200 new cases; 6.5 new cases per 100 000; -17%).

The number of new weekly deaths reported in the Region increased by 7% ascompared to the previous week, with over 5000 new deaths reported. The
highest numbers of new deaths were reported from the United States ofAmerica (2345 new deaths; <1 new death per 100 000; +5%), Brazil (1751 newdeaths; <1 new death per 100 000; +7%), and Mexico (315 new deaths; <1
new death per 100 000; +32%).

The number of new weekly deaths in the Region decreased by 39% ascompared to the previous week, with just under 90 new deaths reported. The
highest numbers of new deaths were reported from South Africa (42 newdeaths; <1 new death per 100 000 population; -34%), Ethiopia (10 new
deaths; <1 new death per 100 000; -23%), and Réunion (six new deaths; <1
new death per 100 000; -14%).

9 000 000

Region of the Americas

50 0006 000 000
4 000

200 000
3 000
150 000
2 000

100 000

60 0007 000 000

5 000

250 000

Cases

8 000 000

Cases
Deaths40 0005 000 000
30 0004 000 000
3 000 000

20 0002 000 000
10 0001 000 000

1 000

50 0000030-Dec20-Jan10-Feb02-Mar23-Mar
13-Apr04-May25-May15-Jun06-Jul
27-Jul17-Aug07-Sep28-Sep19-Oct
09-Nov
30-Nov
21-Dec11-Jan01-Feb
22-Feb15-Mar
05-Apr
26-Apr17-May07-Jun28-Jun19-Jul
09-Aug30-Aug20-Sep11-Oct01-Nov
22-Nov
13-Dec03-Jan24-Jan14-Feb07-Mar28-Mar
18-Apr
09-May30-May20-Jun11-Jul030-Dec20-Jan10-Feb02-Mar23-Mar
13-Apr04-May25-May15-Jun06-Jul
27-Jul17-Aug07-Sep28-Sep19-Oct
09-Nov
30-Nov
21-Dec11-Jan01-Feb
22-Feb15-Mar
05-Apr
26-Apr17-May07-Jun28-Jun19-Jul
09-Aug30-Aug20-Sep11-Oct01-Nov
22-Nov
13-Dec03-Jan24-Jan14-Feb07-Mar28-Mar
18-Apr
09-May30-May20-Jun11-Jul0

Reported week commencing

Reported week commencing

Updates from the African Region

Updates from the Region of the Americas
12

DeathsAfrican Region

Cases

300 000

Cases
Deaths

6 000

Deaths350 000

Eastern Mediterranean Region

European Region

After an increasing trend over the past two months, the Eastern
Mediterranean Region reported over 120 000 new weekly cases, a figure
similar to last week’s figure. Six (27%) countries reported increases in thenumber of new cases of 20% or greater, with some of the highest
proportional increases observed in Libya (453 vs 51 new cases; +788%, partly
due to batch reporting), the Islamic Republic of Iran (25 126 vs 8761 newcases; +187%), and Jordan (2135 vs 1329 new cases; +61%). The highest
numbers of new cases were reported from the Islamic Republic of Iran (25126 new cases; 29.9 new cases per 100 000; +187%), Tunisia (20 903 newcases; 176.9 new cases per 100 000; +50%), and Iraq (19 217 new cases; 47.8
new cases per 100 000; -34%).

The European Region reported over 2.7 million new weekly cases, a 16%
decrease from the previous week. Twenty (33%) countries in the Region
reported increases in new cases of 20% or greater, with the highest
proportional increases observed in Kyrgyzstan (485 vs 78 new cases; +522%),
Romania (34 582 vs 7726 new cases; +348%), and Kazakhstan (7190 vs 2293
new cases; +214%). The highest numbers of new cases were reported from
France (757 830 new cases; 1165.2 new cases per 100 000; -15%), Italy(718 925 new cases; 1205.4 new cases per 100 000; +9%), and Germany(602 930 new cases; 725.0 new cases per 100 000; -3%).
Over 3000 new weekly deaths were reported in the Region, a 14% decrease
as compared to the previous week. The highest numbers of new deaths werereported from Italy (784 new deaths; 1.3 new deaths per 100 000; +37%),
Spain (610 new deaths; 1.3 new deaths per 100 000; -1%), and France(530 new deaths; <1 new death per 100 000; +30%).

The number of new weekly deaths in the Region increased by 15% ascompared to the previous week, with over 200 new deaths reported. The
highest numbers of new deaths were reported from Tunisia (75 new deaths;<1 new death per 100 000; +32%), the Islamic Republic of Iran (57 newdeaths; <1 new death per 100 000; +46%), and Morocco (27 new deaths; <1
new death per 100 000; -23%).

14 000 000
12 000 000

35 0009 000
10 000 000

700 000

7 000

600 000

6 000

500 000

5 000

400 000

4 000

300 000

3 000

200 000

2 000

100 000

1 000

30 0008 000 000

25 0006 000 000

20 000
15 0004 000 000

10 0002 000 000

5 000

0

0
30-Dec20-Jan10-Feb02-Mar23-Mar
13-Apr04-May25-May15-Jun06-Jul
27-Jul17-Aug07-Sep28-Sep19-Oct
09-Nov
30-Nov
21-Dec11-Jan01-Feb
22-Feb15-Mar
05-Apr
26-Apr17-May07-Jun28-Jun19-Jul
09-Aug30-Aug20-Sep11-Oct01-Nov
22-Nov
13-Dec03-Jan24-Jan14-Feb07-Mar28-Mar
18-Apr
09-May30-May20-Jun11-Jul

0

Cases

8 000

0

Reported week commencing

Reported week commencing

Updates from the Eastern Mediterranean Region

Updates from the European Region
13

DeathsEastern Mediterranean Region

45 00040 000Deaths30-Dec20-Jan10-Feb02-Mar23-Mar
13-Apr04-May25-May15-Jun06-Jul
27-Jul17-Aug07-Sep28-Sep19-Oct
09-Nov
30-Nov
21-Dec11-Jan01-Feb
22-Feb15-Mar
05-Apr
26-Apr17-May07-Jun28-Jun19-Jul
09-Aug30-Aug20-Sep11-Oct01-Nov
22-Nov
13-Dec03-Jan24-Jan14-Feb07-Mar28-Mar
18-Apr
09-May30-May20-Jun11-JulCases

800 000

Cases
DeathsDeaths900 000

European Region

CasesSouth-East Asia Region

Western Pacific Region

The South-East Asia Region has been reporting an increasing trend in cases
since early June, with over 173 000 new cases reported, a 5% increase ascompared to the previous week. Three of 10 countries (30%) for which data
were available showed increases in the number of new cases of 20% or
greater, with the greatest proportional increases observed in Nepal (1091 vs
516 new cases; +111%), Sri Lanka (175 vs 106 new cases; +65%) and Indonesia(23 648 vs 17 388; +36%). The highest numbers of new cases were reported
from India (127 948 new cases; 9.3 new cases per 100 000; +6%), Indonesia(23 648 new cases; 8.6 new cases per 100 000; +36%), and Thailand (13 986
new cases; 20 new cases per 100 000; -6%).

The Western Pacific Region reported over 1.4 million new cases, a 37%
increase as compared to the previous week. Fourteen (42%) countries
reported increases in new cases of 20% or greater, with some of the largest
proportional increases observed in the Lao People's Democratic Republic(149 vs 55 new cases; +171%), Japan (559 111 vs 269 760 new cases; +107%),and the Republic of Korea (249 912 vs 122 234 new cases; +104%). The
highest numbers of new cases were reported from Japan (559 111 new cases;
442.1 new cases per 100 000; +107%), the Republic of Korea (249 912 newcases; 487.5 new cases per 100 000; +104%), and Australia (229 874 newcases; 901.5 new cases per 100 000; -11%).

The number of new weekly deaths in the Region increased by 20% ascompared to the previous week, with over 500 new deaths reported. The
highest numbers of new deaths were reported from India (281 new deaths;<1 new death per 100 000; +23%), Thailand (161 new deaths; <1 new deathper 100 000; +19%), and Indonesia (58 new deaths; <1 new death per 100000; +38%).

The Region reported over 1300 new weekly deaths, similar to the figure
reported during the previous week. The highest numbers of new deaths werereported from China (576 new deaths; <1 new death per 100 000; -17%),Australia (293 new deaths; 1.1 new deaths per 100 000; -1%), and Japan (164
new deaths; <1 new death per 100 000; +52%).

South-East Asia Region

6 000 000
30 0002 500 000

25 0002 000 000

20 0001 500 000

15 0001 000 000

10 000500 000

5 000

Cases

Western Pacific Region

6 000
5 000

4 000 000

4 000
3 000 000

3 000

2 000 000

2 000

1 000 000

1 000

030-Dec20-Jan10-Feb02-Mar23-Mar
13-Apr04-May25-May15-Jun06-Jul
27-Jul17-Aug07-Sep28-Sep19-Oct
09-Nov
30-Nov
21-Dec11-Jan01-Feb
22-Feb15-Mar
05-Apr
26-Apr17-May07-Jun28-Jun19-Jul
09-Aug30-Aug20-Sep11-Oct01-Nov
22-Nov
13-Dec03-Jan24-Jan14-Feb07-Mar28-Mar
18-Apr
09-May30-May20-Jun11-Jul0030-Dec20-Jan10-Feb02-Mar23-Mar
13-Apr04-May25-May15-Jun06-Jul
27-Jul17-Aug07-Sep28-Sep19-Oct
09-Nov
30-Nov
21-Dec11-Jan01-Feb
22-Feb15-Mar
05-Apr
26-Apr17-May07-Jun28-Jun19-Jul
09-Aug30-Aug20-Sep11-Oct01-Nov
22-Nov
13-Dec03-Jan24-Jan14-Feb07-Mar28-Mar
18-Apr
09-May30-May20-Jun11-Jul0

Reported week commencing

Reported week commencing

Updates from the South-East Asia Region

Updates from the Western Pacific Region

14

8 000
7 000

Deaths5 000 000

Cases

Cases
DeathsDeathsCases

3 000 000

35 000Deaths7 000 000
3 500 000

Annex 1. Data, table, and figure notes
Data presented are based on official laboratory-confirmed COVID-19 cases and deaths reported to WHO by
country/territories/areas, largely based upon WHO case definitions and surveillance guidance. While steps are taken to
ensure accuracy and reliability, all data are subject to continuous verification and change, and caution must be taken wheninterpreting these data as several factors influence the counts presented, with variable underestimation of true case anddeath incidences, and variable delays to reflecting these data at the global level. Case detection, inclusion criteria, testing
strategies, reporting practices, and data cut-off and lag times differ between countries/territories/areas. A small numberof countries/territories/areas report combined probable and laboratory-confirmed cases. Differences are to be expected
between information products published by WHO, national public health authorities, and other sources.
A record of historic data adjustment made is available upon request by emailing epi-data-support@who.int. Please specify
the countries of interest, time period, and purpose of the request/intended usage. Prior situation reports will not beedited; see covid19.who.int for the most up-to-date data. COVID-19 confirmed cases and deaths reported in the last
seven days by countries, territories, and areas, and WHO Region (reported in previous issues) are now available at:https://covid19.who.int/table.
‘Countries’ may refer to countries, territories, areas or other jurisdictions of similar status. The designations employed,
and the presentation of these materials do not imply the expression of any opinion whatsoever on the part of WHO
concerning the legal status of any country, territory, or area or of its authorities, or concerning the delimitation of its
frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not
yet be full agreement. Countries, territories, and areas are arranged under the administering WHO region. The mentionof specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by
WHO in preference to others of a similar nature that are not mentioned. Errors and omissions except, the names ofproprietary products are distinguished by initial capital letters.
[1]

All references to Kosovo should be understood to be in the context of the United Nations Security Council resolution
1244 (1999). In the map, the number of cases of Serbia and Kosovo (UNSCR 1244, 1999) have been aggregated forvisualization purposes.
[2]
Since 21 May 2022, data for COVID-19 cases and deaths in Northern Ireland was no longer included in the United
Kingdom updates.
[3]
Updates of an outbreak of COVID-19 reported in the Democratic People’s Republic of Korea continue through official
media since 12 May 2022; however, at present, no confirmed cases or deaths have been reported to WHO.

15

Annex 2. SARS-CoV-2 variants assessment and classification
WHO, in collaboration with national authorities, institutions and researchers, routinely assesses if variants of SARSCoV-2 alter transmission or disease characteristics, or impact the effectiveness of vaccines, therapeutics, diagnostics
or public health and social measures (PHSM) applied to control disease spread. Potential variants of concern (VOCs),variants of interest (VOIs) or variants under monitoring (VUMs) are regularly assessed based on the risk posed to
global public health.
The classifications of variants will be revised as needed to reflect the continuous evolution of circulating variants andtheir changing epidemiology. Criteria for variant classification, and the lists of currently circulating and previously
circulating VOCs, VOIs and VUMs, are available on the WHO Tracking SARS-CoV-2 variants website. National
authorities may choose to designate other variants and are strongly encouraged to investigate and report newly
emerging variants and their impact.1

16

Annex 3. Summary of Primary Series and First Booster Vaccine Performance against Omicron Variant of Concern (data as of 11 July 2022)
Omicron Sub-Lineage
BA.1

BA.2

BA.2.12.1

BA.3

BA.4/BA.5

AstraZeneca-Vaxzevria/SII-Covishield

HNR10

HNR1

----

----

----

Beijing CNBG-BBIBP-CorV

HNR7

HNR2

HNR1

HNR1

HNR1

Bharat-Covaxin

↓↓1

----

----

----

----

Cansino-Convidecia

----

----

----

----

----

Janssen-Ad26-COV2.S

HNR6

----

----

----

----

Moderna-Spikevax----

Primary Series Vaccination

WHO Emergency
Use Listing (EUL)
Qualified Vaccines

Vaccines without
WHO EUL

↓↓↓10

HNR2

----

----

Novavax-Nuvaxovid/SII - Covavax

----

----

----

----

----

Pfizer BioNTech-Comirnaty

HNR47

↓↓↓2

----

HNR1

HNR1

Sinovac-CoronaVac

↓↓↓1
----

-------

----

----

----

Anhui ZL-Recombinant

----

----

----

Gamaleya-Sputnik V

HNR2

----

----

----

----

AstraZeneca-Vaxzevria/SII-Covishield + AstraZeneca-Vaxzevria/SII Covishield

HNR2

HNR2

----

↓↓1

↓↓↓1

AstraZeneca-Vaxzevria/SII-Covishield + Moderna-Spikevax

↓1

----

----

----

----

Booster Vaccination (Primary Series Vaccine + Booster Vaccine)

AstraZeneca-Vaxzevria/SII-Covishield + Pfizer BioNTech-Comirnaty

↓↓1

↓↓1

----

↓↓1

----

↓↓to↓↓↓4

HNR2

HNR1

↓↓1

HNR1

Janssen-Ad26-COV2.S + Janssen-Ad26-COV2.S

HNR1

----

----

----

----

Janssen-Ad26-COV2.S + Pfizer BioNTech-Comirnaty

↓1

----

----

----

----

↓to↓↓↓9

↓↓1

↓↓1

↓↓1

↓↓↓1

↓↓↓1

----

----

----

----

↓to↓↓↓40↓to↓↓13↓to↓↓↓3↓to↓↓4↓↓to↓↓↓5

Pfizer BioNTech-Comirnaty + Janssen-Ad26-COV2.S

↓2

----

----

----

----

Pfizer BioNTech-Comirnaty + Moderna-Spikevax↓to↓↓2

----

----

----

----

HNR6

↓↓2

↓↓1

↓↓1

↓↓1

Sinovac-CoronaVac + Pfizer BioNTech-Comirnaty

↓↓2

↓↓1

----

----

----

Anhui ZL-Recombinant + Anhui ZL-RecombinantBeijing CNBG-BBIBP-CorV + Anhui ZL - Recombinant↓to↓↓2↓↓to↓↓↓4

↓↓1
HNR2

↓↓1
HNR1

↓↓↓1
↓↓↓1

↓↓↓1
HNR1

Gamaleya-Sputnik V + Gamaleya Sputnik Light

↓↓1

----

----

----

----

Sinovac-CoronaVac + Anhui ZL - Recombinant↓to↓↓2↓to↓↓2↓to↓↓↓2↓to↓↓↓2↓↓1

Beijing CNBG-BBIBP-CorV + Beijing CNBG-BBIBP-CorV
WHO Emergency
Use Listing (EUL)
Qualified Booster
Vaccines

Moderna-Spikevax + Moderna-Spikevax
Moderna-Spikevax + Pfizer BioNTech-Comirnaty
Pfizer BioNTech-Comirnaty + Pfizer BioNTech-Comirnaty

Sinovac-CoronaVac + Sinovac-CoronaVac

Booster Vaccines
without WHO EUL

Abbreviations: HNR=high non-response. Arrows generalize the magnitude of reduction in VE or neutralization: “↔” indicates <2-fold reduction in neutralization; “↓” indicates 2 to <5-fold reduction; “↓↓” indicates 5 to <10-fold reduction; “↓↓↓”indicates ≥10-fold reduction. When more than one neutralization study is available, the interquartile range (25th and 75th percentiles) of fold-reductions across all studies for specific vaccine/sub-lineage was used. HNR indicates a median percent
response across all studies of <75%; in these instances, fold-reductions can be biased and, thus. are not presented. The number of studies is shown as subscripts.

17Additional notes on Annex Table 3••••

Studies contributing to the table are identified from an ongoing review of the preprint andpublished literature on neutralization of SARS-CoV-2 variants by COVID-19 vaccines.
Studies that use samples collected >7 days and < 6 months after complete vaccination and thatuse an ancestral strain as the reference are included in the table.
Studies of immunocompromised persons are excluded.
It is important to note that studies vary in population and other methodological considerations
which may in part explain some differences when comparing products between different studies.
In addition, the reductions summarised in the table do not incorporate uncertainty intervals
around the fold reductions which can vary substantially across studies when reported.

Annex 4. Methods for Figure 5
•

•

•

•

VE studies included in the plot were identified from an ongoing systematic review of COVID-19
vaccine effectiveness studies. All studies were cohort or test-negative designs conducted when
Omicron was the predominant circulating variant. Methods for the systematic review andinclusion/exclusion criteria are available on view-hub.org.
Only studies providing VE estimates of individual vaccines are included in the plot; studies
assessing combined VE of more than one vaccine are excluded except for studies of heterologous
primary and booster schedules where all participants included in a VE estimate received the samebrands of vaccines in the same order.
Only studies providing VE estimates for discrete time intervals since vaccination or estimates withlimited follow-up time (such that the median time point falls clearly in one of the intervals for theplot) are included. Studies that only provide VE estimates over a cumulative period of timecovering more than one time interval are excluded because they are difficult to interpret due tothe marked waning of VE over time with Omicron.
Only estimates of absolute vaccine effectiveness (i.e., the comparison group is unvaccinatedpersons) are included in the plot; estimates of relative vaccine effectiveness (e.g., the comparisongroup is persons having completed the primary series) are excluded as the interpretation ofrelative vaccine effectiveness is not comparable with absolute vaccine effectiveness.

18

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21

Reopen for International Travel Without COVID-19 Testing Required（142 Member States）
Updated on 19 July, 2022
Albania

Effective May 1, 2022, the Government of Albania repealed COVID-19-related entry requirements.(Last updated: 06/11/2022)

https://al.usembassy.gov/updates_covi
d19/

Algeria

Effective March 20, 2022, passengers can enter Algeria without restriction if they are fully vaccinated and if their last vaccine is not older
than 9 months.Non-vaccinated passengers and those whose vaccinations are older than 9 months must have a negative PCR test within
72 hours of the time of arrival.

https://dz.usembassy.gov/covid-19information/

AndorraThe Andorran authorities have taken no measures to close the borders and movement into the country. The Government of Andorra istherefore currently applying no restrictions on entering the country, nor on the movement of people and vehicles around its territory.

https://visitandorra.com/en/covid-19-inandorra/faq-if-you-re-spending-a-fewdays-in-andorra/

Arriving passengers are not required to present verifiable documentation of full vaccination to be permitted entry into Antigua andAntigua and Barbuda.Fully vaccinated arriving passengers are not required to present a PCR/Rapid Antigen Test negative result to be permitted entry
Barbuda into Antigua and Barbuda, (unless they show symptoms of possible infection). This includes transiting passengers.((Last
updated:04/16/2022)
Argentina

Travelers are not required to provide proof of a negative COVID-19 test result before traveling to Argentina.People who have an
incomplete vaccination schedule are recommended to have a diagnostic test within 24 hours of their entry into the country.

https://visitantiguabarbuda.com/traveladvisory/https://www.argentina.gob.ar/interior/mi
graciones/ddjj-migraciones

According to the amendments of the Government Decree: № 1514-N of September 11, 2020, which entered into force on May 1, 2022:
Armenia

The passengers are NO LONGER REQUIRED to present a COVID-19 PCR test or a Certificate of complete vaccination against COVID19 to enter the Republic of Armenia.

https://www.gov.am/en/covid-travelrestrictions/

Australia

Changes to the requirements for travel into and out of Australia came into effect on 18 April 2022. The Australian Government no longer
requires people travelling to Australia to have a COVID-19 test before travel.You do not need to provide proof of COVID-19 vaccination to
travel to and from Australia.

https://www.health.gov.au/healthalerts/covid-19/internationaltravel/inboundAustria

Travel to Austria is possible for touristic purposes.Since 16 May, proof of vaccination/recovery or a test are no longer needed.(Last
update: 2022/05/17)

https://www.austria.info/en/service-andfacts/coronavirus-information/entryregulations

Azerbaijan The Cabinet of Ministers announced that, beginning April 15, 2022, the need for a negative PCR test for entry to Azerbaijan is eliminated.

https://az.usembassy.gov/covid-19information-for-azerbaijan/

BahamasEffective Sunday 19th June 2022 at 12:01 am The Bahamas Travel Health Visa (BTHV) will no longer be required to travel to The
Bahamas.
All unvaccinated travelers ages 2 and older will be required to obtain a negative COVID-19 test - either a negative RT-PCR or a
Rapid Antigen Test to be presented at check-in.
Vaccinated travelers will only be required to present proof of vaccination at check-in.

https://travel.gov.bs/

BahrainStarting from 20 February 2022, All passengers arriving in the Kingdom of Bahrain do not need to conduct a PCR test upon
arrival.Cancellation of the precautionary quarantine for all passengers arriving in the Kingdom of Bahrain.

https://healthalert.gov.bh/en/article/entr
y-procedures-through-kingdom-ofbahrain

1) Vaccinated with Covid-19 vaccine:Travelers completed full dose (single/double dose as applicable for a full dose) of WHO approved
Covid-19 vaccine can enter Bangladesh with the official proof of certification of vaccination and no RT PCR based COVID-19 negativecertificate is required.
Bangladesh2) Not vaccinated with Covid-19 vaccine:Travelers without having full dose (single/double dose as applicable for a full dose) of Covid-19
vaccine can enter Bangladesh if they possess RT PCR based COVID-19 negative certificate done within 72 hours of departure time
(Last update: 2022/06/02)

http://caab.gov.bd/circul/AT-CircularFSR-03-2022%20(02June22).pdf

Barbados

Effective Wednesday, May 25, 2022, fully-vaccinated travellers to Barbados will no longer have to take a COVID-19 test to enter thecountry.

https://www.visitbarbados.org/covid-19travel-guidelines-2022

Belarus

There are no restrictions on entry into Belarus for citizens of Belarus, foreign citizens and stateless persons.

https://gpk.gov.by/covid-19/

Belgium

From 23 May 2022, measures will only apply to travellers coming from a very high risk country.

https://www.infocoronavirus.be/en/travels/

BelizeEffective March 1, 2022, fully vaccinated travellers no longer require a negative test but must show proof of vaccination for entry into
Belize’s airport, land borders or sea ports.If unable to show proof or if unvaccinated, the traveller must present proof of a negative PCR
result taken within 72 hours of arrival or a negative Antigen Rapid test taken within 48 hours of arrival. A test can be administered by the
Ministry responsible for health at the airport.
Every child under the age of 5 years shall not be subjected to testing for SARSCoV2 upon entry into Belize through airport, land or sea
port.

https://belizetourismboard.org/news-andgallery/belize-covid-19-travelupdates/#1644266913182-1e31ba74-2de7

Benin

There is no negative COVID-19 test (PCR and/or serology) required for entry Benin.(Last updated: 06/16/2022)

https://bj.usembassy.gov/info-covid19/

Bolivia

Travelers to Bolivia must comply with the following requirements.(Last Updated 6/13/22)
Present a COVID-19 vaccination certificate, or
Present a negative COVID-19 RT-PCR test (for persons older than 5 years) taken no more than 72 hours prior to embarkation, or
Present a negative COVID-19 nasal antigen test (for persons older than 5 years) no more than 48 hours prior to embarkation.

https://bo.usembassy.gov/covid-19information/

Bosnia andAs of May 26, 2022, BiH authorities have removed entry restrictions related to COVID-19.
Herzegovina

Bostswana

https://granpol.gov.ba/Content/Read/74?title=COVID-19

Fully vaccinated travelers with proof of a booster dose do not need to present negative COVID-19 test results.Others are required to showhttps://covid19portal.gov.bw/node/1017
proof of a negative PCR COVID-19 test within 72 hours of travel and must submit to vaccination on arrival at the Port of Entry.

Brazil

Fully vaccinated travelers are not required to present proof of negative COVID-19 test results before traveling to Brazil.

https://www.in.gov.br/en/web/dou//portaria-interministerial-n-670-de-1-deabril-de-2022-390351794

Brunei

In view of the opening of borders via air travel on 6th May 2022, the COVID-19 Steering Committee would like to inform the public on theeasing of cross-border travel restrictions and the updates of control measures which will also commence on Wednesday, 15th June 2022,
as follows:1)Pre-departure swab test (either (RT-PCR or ART test) for inbound travellers is no longer required, regardless of vaccination status.
2)Fully vaccinated travellers are no longer required to undergo ART testing and self-isolation upon arrival in the country.
3)Travellers who have not completed the COVID-19 vaccination are required to undergo ART testing upon arrival, three (3) days selfisolation and will only be allowed to end their self-isolation if tested negative RT-PCR on day three.( Last updated: 06/09/2022)

https://www.bruneitourism.com/covid19travellers-advisory/Bulgaria

Burkina Faso

As of 1 May 2022, the restrictions on entry into the territory of the Republic of Bulgaria are lifted.
Fully vaccinated travelers are not required to have a negative COVID-19 test result before traveling to Burkina Faso.(Last updated:06/03/
2022)

If you’re fully vaccinated, you can enter Cape Verde without needing to test or quarantine but you will need to present proof of yourvaccination status when you check-in for your flight to Cape Verde. If you’re not fully vaccinated, you’ll need to show proof of a negative
PCR test (taken no more than 72 hours before you travel) or an antigen test (taken no more than 48 hours before you travel) when you
Cabo Verdecheck-in for your flight to Cape Verde. If you’re not fully vaccinated but have tested positive for COVID-19 in the last year, you can enter
Cape Verde with a COVID-19 recovery certificate showing you recovered from COVID-19 no less than 11 days and no more than 180
days before you travel.

Cambodia

CanadaAs of March 17 2022, the Royal Government of Cambodia has officially decided as follow: 1)Lift the requirement that travelers fromabroad shall present a negative PCR Test Result of COVID-19 within 72 hours prior arriving in Cambodia. 2)Lift the requirement for
Antigen Rapid Test upon arrival in Cambodia. 3) Resume the issuance of Visa on arrival for international travelers by air, land and sea.

Starting April 1, 2022, pre-entry tests are no longer required for fully vaccinated travellers entering Canada by land, air or water.
Unvaccinated and partially vaccinated children 5 years of age or older must provide a valid pre-entry test result, even if they areaccompanying a fully vaccinated adult.
Children who are less than 5 years old are not required to test, regardless of their vaccination status.

https://coronavirus.bg/bg/azsum/zavrashtam-se-bulgaria

https://www.sante.gov.bf/covid19

https://www.gov.uk/foreign-traveladvice/cape-verde/entry-requirements

https://www.embassyofcambodiadc.org/
embassy-updates/pr-no-098-easing-ofentry-requirements-march-17-2022
https://travel.gc.ca/travel-covid/travelrestrictions/flying-canadachecklist/covid-19-testing-travellerscoming-intocanada?utm_campaign=gac-amccovid-20-21&utm_source=travelcovid_travelrestrictions_flying_&utm_medium=redir
ect&utm_content=en

Chad

If you’re fully vaccinated, you can enter Chad without needing to test or quarantine.You must present proof that you have been fully
vaccinated to enter Chad.If you’re not fully vaccinated, you’ll need to show proof of a negative PCR test (taken no more than 96 hours
before entry) in order to enter Chad.

https://www.gov.uk/foreign-traveladvice/chad/entry-requirements

Colombia

International travelers who entered Colombia should not present a negative PCR test to enter the country. They only have to do their
Check-Mig registration 24 hours before their flight at the following link: migracioncolombia.gov.co.

https://colombia.travel/en/covid-19information

Cook Islands From 1 May, pre-departure testing has been removed for all international arrivals

https://cookislands.travel/entry

Costa Rica

Starting April 1, the temporary migration measures established in the framework of the national health emergency due to COVID-19 are
repealed.

https://www.visitcostarica.com/en/costarica/planning-your-trip/entryrequirements

Côte d’Ivoire

With effect from 7 March 2022, the Ministry of Health, Public Hygiene and Universal Health Coverage has announced that you no longer
need to show a negative PCR test as long as you can prove that you are fully vaccinated. If you are not fully vaccinated, you will still needto show evidence of a negative COVID-19 test result, dated a maximum of 72 hours prior to arrival, before being allowed to board yourflighthttps://www.gov.uk/foreign-traveladvice/cote-d-ivoire/entryrequirements

Croatia

Croatia removed all border crossing restrictions, notably the requirement for non-EU citizens to present a COVID-19 certificate or proof of
vaccination for entry to Croatia. There are no longer any COVID-related restrictions for entry to Croatia.(Last updated: 06/24/2022)

https://hr.usembassy.gov/covid-19information/

Cuba

In accordance with the international and national epidemiological situation of COVID-19 and the levels of immunization achieved, it has
been decided to make the following modifications to the entry requirements to the country as part of the International Health Control.
1) Eliminate as a requirement for entry to the country the presentation of a test for COVID-19 (Antigen Test or PCR-RT) carried out in the
country of origin, as well as the certificate of vaccination against COVID-19.2) Maintain the sampling for SARS CoV-2 study (free)randomly to travelers at the points of entry into the country, taking into account the number of flights, the entry of boats and theepidemiological risk represented by the country of origin.

https://www.mintur.gob.cu/protocolos/

Cyprus

Effective 1 June 2022, all travellers arriving in the Republic of Cyprus, irrespective of their country of origin, will not be required to present
a valid certificate of vaccination or recovery or a negative result from a PCR or antigen rapid test.

https://www.pio.gov.cy/coronavirus/uploads/27052022_airportsportsactionplana
bolished_EN.pdf

Czechia

https://www.mvcr.cz/mvcren/article/asAs of 9th April 2022, the protective measures regarding the conditions of entry into the Czech Republic in relation to the epidemic of covidof-december-27th-2021-the-rules-for19 have been suspended. Entry into the Czech Republic is no longer subject to any special epidemiological conditions to prevent theentry-into-the-czech-republic-will-bespread of the disease. The entry-ban for foreigners from third-countries and the obligation to prove infection-free status have been lifted.
tightened-for-foreign-nationals.aspx

Denmark

There are no covid-19 related restrictions on entry into Denmark. On this page, you will find information on testing and everyday
precautions.(Updated: 4 July 2022)

https://en.coronasmitte.dk/travelrules/covidtravelrules

As of April 4th, travellers will no longer be required to fill and submit the pre-travel online form.
Dominica

The requirement for pre-arrival testing, and testing on arrival for vaccinated travellers at all ports of entry, including seafarers andyachters, has been removed.

https://discoverdominica.com/en/traveladvisory-for-dominica

Dominican
Republic

As of April 23, 2022, all passengers and crew members do not need to present a COVID-19 Vaccination Card, PCR, or antigen test toenter the Dominican Republic or to enter tourist centers, any establishments or to receive services such as excursions.

https://www.godominicanrepublic.com/newsroom/coronavirus/

Egypt

All passengers traveling to Egypt (including Egyptians) must be in possession of a vaccination certificate or a negative PCR, Antigen
Rapid Test, or ID NOW test result for COVID-19 with Quick Response (QR) code, taken at a maximum of 72 hours before their flightdeparture time.(Last updated: 06/12/ 2022)

https://eg.usembassy.gov/u-s-citizenservices/covid-19-information/

The Government of El Salvador has removed COVID-19 testing/vaccination requirements for entry. Visitors are advised however to bring
proof of vaccination with them, as this may be requested for entry into certain events or locations in El Salvador.

https://www.dfa.ie/travel/travel-advice/az-list-of-countries/el-salvador/

El Salvador

Estonia

COVID-19 travel restrictions have been lifted in Estonia. Travellers are not required to provide proof of vaccination, recovery from COVID- https://www.visitestonia.com/en/covid19 or a negative test result.
19-and-travelling-to-estonia

Eswatini

As at March 2022, Eswatini is open to all visitors based on the following requirements:
Travellers entering and exiting the Kingdom of Eswatini must produce EITHER of the following, upon arrival at the Points of Entry:
A valid COVID-19 vaccination certificate (hard or electronic) and must be fully vaccinated.
OR
A valid negative COVID-19 PCR test result (hard or electronic) that is not older than 72 hours, for the unvaccinated.

https://www.thekingdomofeswatini.com/travel-advice/Ethiopia

Passengers age 12 and over who have been fully vaccinated against COVID-19 more than two weeks before the date of entry are
required to show evidence of this. Accepted vaccinations are a single dose of Johnson and Johnson, or two doses for Astra-Zeneca,
Sinopharm, Sinovac, Moderna and Pfizer.Travellers under the age of 12 do not need to show proof of vaccination.
If you’re not fully vaccinated, you’ll need to show proof of a negative COVID-19 RT PCR test result issued within the 72 hours (3 days)
before departure, or a rapid lateral flow test up to 24 hours before arriving in Ethiopia.

https://www.gov.uk/foreign-traveladvice/ethiopia/entry-requirements

Restrictions on entry at Finland’s external borders imposed due to the COVID-19 pandemic will end on 30 June, 2022.
FinlandThis means that EU travellers, Schengen travellers and third-country travellers arriving in Finland will no longer be required to holdvaccination or COVID-19 test certificates, and COVID-19 tests will not be carried out at border crossing points.

https://www.visitfinland.com/en/practical-tips/covid-19/

Border checks will return to pre-pandemic procedures.
Covid-19 restrictions at the French border were eased on 12 February 2022 for fully vaccinated travellers.
The entry conditions to French territory are defined by the classification of departure countries (countries and territories on ’green’ and’orange’ lists) indicated below. Children under 12 years of age are exempt from testing.(Updated on June 13th, 2022)
Francehttps://www.diplomatie.gouv.fr/en/coming-to-france/coming-to-france-yourcovid-19-questionsanswered/article/coming-to-france-yourcovid-19-questionsanswered?var_mode=calcul

Gabon

Travelers are not required to take a negative COVID-19 test (PCR and/or serology) result.(Last updated: 06/13/2022)

https://ga.usembassy.gov/u-s-citizenservices/coronavirus-update/GambiaAs of December 11, 2021, the Ministry of Health updated entry requirements into The Gambia:
Fully vaccinated travelers into The Gambia do not need a PCR test to enter. However, if such individuals have signs or symptoms similar
to those of COVID-19, they will be required to undergo Rapid Diagnostic Test for COVID-19 at the airport.
Non-Vaccinated or Partially Vaccinated individuals will need a negative PCR test report valid within 72 hours for entry into the country.
Individuals who test positive for COVID-19 upon arrival, will be required to undergo mandatory quarantine at the traveler’s own
expense.(Last updated: 06/14/2022)

https://gm.usembassy.gov/covid-19information/

Georgia

From March 1, 2022, citizens of all countries, traveling by air, land, or sea from any country may enter Georgia if they present the
document confirming the full course of any COVID-19 vaccination OR present a negative PCR test taken within 72 hours (96 h)https://georgia.travel/en_US/article/covi
d-travel-alert

Germany

Lifting of COVID-19-related restrictions for entry into Germany with effect as of Saturday, 11 June 2022, 12pm/0.00h CET

https://www.bmi.bund.de/SharedDocs/fa
qs/EN/topics/civilprotection/coronavirus/coronavirusfaqs.html

Ghana

Vaccinated travelers do not need to show a negative COVID-19 test.(Last updated: 06/13/2022)

https://gh.usembassy.gov/ghana-covid19-information/

GreeceFrom 15 March 2022 onwards, travellers visiting Greece are no longer required to fill out the Passenger Locator Form (PLF).
Additionally, as of Sunday 01.05.2022 and for as long as the epidemiological data allow so, all travellers arriving in Greece, regardless of
their country of origin, are no longer required to display a valid certificate of vaccination or recovery from COVID-19, or evidence of anegative test result from SARS-CoV-2 infection (PCR or Rapid Antigen test).

https://travel.gov.gr/#/GrenadaState of emergency revoked and all travel protocols lifted on 04th April 2022. (Last updated: 6/08/2022)

https://bb.usembassy.gov/covidinformation-grenada/Effective March 11, 2022, the Government of Guatemala has imposed the following COVID-related entry requirements:
Passengers who are Guatemalan citizens, foreigners, residents, accredited diplomats, or airline crew whose final destination is Guatemalamust present one of the following:https://gt.usembassy.gov/alert-covidGuatemala For all travelers aged 12 and over: Evidence of receiving a complete two-dose COVID-19 vaccination course (or one dose for Johnson &19-2/
Johnson), with the final dose being administered at least two weeks before beginning your trip to Guatemala; or
For all travelers aged 10 and over: Proof of a negative COVID-19 PCR or antigen test from a certified lab conducted no more than three(3) days prior to check in at the airport or arrival at the land border.

GuineaThe Ministry of Health announced on 11 March 2022 that fully vaccinated travellers entering or leaving Guinea are not required to show
proof of a negative certificate from a polymerase chain reaction (PCR) test.

https://www.gov.uk/foreign-traveladvice/guinea/entryrequirements#entry-rules-in-responseto-coronavirus-covid-19

GuineaBissau

Travelers who have been fully vaccinated against COVID-19 at least four weeks prior to arrival into Guinea-Bissau are not required anegative COVID-19 test (PCR and/or serology) for entry.(Last updated: 06/27/2022)

https://gw.usmission.gov/covid-19information/

Haiti

Haiti is putting new COVID requirements in place as of April 25, 2022. Fully vaccinated visitors will no longer need to present a negative
COVID-19 antigen or PCR test taken within 72 hours of travel. But the testing requirement will stay in place for unvaccinated visitors.

https://www.mspp.gouv.ht/

Effective June 2, 2021, The Government of Honduras has updated its requirements for entry into the country. All travelers must still
complete the online pre-check form, but fully vaccinated individuals with their original vaccination certificate are no longer required toprovide proof of a negative COVID test upon entry in Honduras.
1)Proof of Full Vaccination: Passengers must provide the original vaccination certificate documenting complete COVID-19 vaccination(two doses of most vaccines; one dose of Johnson & Johnson) with at least 14 days after receipt of the final dose.
2)COVID-19 Test: Passengers who cannot provide proof of full vaccination must hand-carry the negative test results for a PCR, Antigen
or ELISA COVID-19 test taken less than 72 hours before entry into Honduras. Passengers must show the test results at check-in.
(Last updated: 6/13/2022)
On 7 March 2022, Government Decree No. 77 of 2022 (III. 4.) on the termination of certain safety measures against the coronavirus
pandemic entered into force, which repealed Government Decree No. 408 of 2020 (VIII. 30.) on travel restrictions during the period ofstate of epidemiological preparedness.
In accordance with this, it is possible to enter the territory of Hungary by public road, railway, water and air traffic – regardless of
citizenship and protection against the coronavirus –, but other general conditions of entry (e.g. a valid travel document) must be provided.

https://hn.usembassy.gov/covid-19information/

Iceland

There are no COVID-19 restrictions in Iceland, either domestically or at the border.

https://island.is/en/p/entry

India

All travellers should Upload a negative COVID-19 RT-PCR report* (The test should have been conducted within 72 hrs prior toundertaking the journey) or Certificate of completing full primary vaccination schedule of COVID-19 vaccination

GuidelinesforInternationalarrivalsupdate
don10thFebruary2022.pdf(mohfw.gov.in)

Honduras

Hungary

Indonesia

Iraq

https://www.police.hu/en/content/forthe-attention-of-travelers

https://covid19.go.id/artikel/2022/07/08/
Travelers are not required to have a negative pre-departure COVID-19 test result before traveling to Indonesia.(Updated on July 08, 2022) surat-edaran-kasatgas-nomor-22-tahun2022
Effective April 1, 2022, outbound and inbound travelers above the age of 12 to all federal Iraq and Iraqi Kurdistan Region airports must
present a certificate of vaccination showing at least two doses of one of the COVID-19 vaccines or one dose of Johnson & Johnson’s
Janssen COVID-19 vaccine. If a traveler is unvaccinated, then they are required to provide medical reports on why they cannot get
vaccinated and show a negative COVID-19 PCR certificate valid within 72 hours of travel.(Last updated: 05/15/2022)

https://iq.usembassy.gov/covid-19information/

Ireland

From Sunday 6 March 2022, travellers to Ireland are not required to show proof of vaccination, proof of recovery or a negative PCR test
result upon arrival.
There are no post-arrival testing or quarantine requirements for travellers to Ireland.

https://www.gov.ie/en/publication/77952-government-advice-on-internationaltravel/#passengers-arriving-into-irelandfrom-outside-eueea-eu-icelandlichtenstein-and-norway

As of Friday, May 20, at midnight (on the night between Friday and Saturday, May 21), the following guidance will take effect:
IsrealItaly

Jamaica

JordanIt will not be required to present a negative result on a COVID test before boarding a flight to Israel or a cruise to Israel or before arriving
at an Israeli land border crossing.

https://corona.health.gov.il/en/abroad/ar
riving-foreign-nationals/

https://www.esteri.it/en/ministero/normat
COVID-19 travel restrictions have been lifted in Italy. Providing proof of vaccination, recovery from COVID-19 or negative test results is no ivaonline/focus-cittadini-italiani-inlonger required.
rientro-dall-estero-e-cittadini-stranieri-initalia/
The requirement for travellers to present a negative COVID test prior to travel has ended on 15 April. All travellers arriving in Jamaica
may still be tested for COVID-19 if assessed as high-risk as a result of exhibiting symptoms, exposure to people who have tested positive, https://www.gov.uk/foreign-traveladvice/jamaica/entry-requirements
belonging to a high-risk group or other risk factors. Travellers may be screened for symptoms at the airport.
The government announced on 17 Feb 2022 that travelers to the Kingdom, whether Jordanians or foreigners, are no longer required toundergo a PCR test upon arrival to the Kingdom via any entry point.

Kazakhstan Travelers are not required to have a negative COVID-19 test result before traveling to Kazakhstan.(Last updated: 06/13/2022)

http://international.visitjordan.com/MediaCenter/ShowNews/33#news
https://kz.usembassy.gov/covid-19information/

Kenya

FROM 11th March 2022, All travelers arriving into Kenya through any point of entry must have a certificate of COVID 19 vaccination.All
travelers coming to Kenya who are fully vaccinated shall be exempt from the requirement of a PCR test.

https://www.kcaa.or.ke/sites/default/files/covid-19/documents/COVID19_TRAVEL_REQUIREMENTS_13.3.2
022.pdf

KuwaitNegative COVID-19 test (PCR) is no longer required for entry.(Last updated: 06/12/2022)

https://kw.usembassy.gov/covid-19information/

Travelers no longer need to provide a negative PCR test result or a certificate of vaccination to be permitted entry into the Kyrgyz
Republic(Last updated: 6/14/2022)

https://kg.usembassy.gov/covid-19information/

Kyrgyzstan

Laos

Travelers must have a certificate of vaccination to prove that they are fully vaccinated. Fully vaccinated travelers are not required to have https://la.usembassy.gov/covid-19a negative COVID-19 test result before arrival in Laos.(Last updated: 06/13/2022)
information/

LatviaFrom April 1, when entering Latvia, you will not need a COVID-19 certificate or test.

https://www.spkc.gov.lv/lv/valstusaslimstibas-raditaji-ar-covid-19-0

LebanonFully vaccinated travelers are not required to have a negative COVID-19 test result before traveling to Lebanon.

https://www.moph.gov.lb/en/MoPHPASSLithuania

FROM 1st MAY 2022:
Travelers arriving in Lithuania from any country of the world will no longer be subject to any COVID-19 management requirements:
1)you will no longer need to take the COVID-19 test before the trip, even if you are not vaccinated or recovered from COVID-19;
2)you will not need to fill in the questionnaire;3)foreigners are not prohibited from entering.

https://nvsc.lrv.lt/en/information-oncovid-19/for-arrivals-from-abroad

Luxembourg

From 22 April 2022, the additional health measures for travel by air to the Grand Duchy are repealed. Thus, persons (of all nationalities)
aged 12 years and 2 months or over, authorised to enter Luxembourg, are no longer required to present, upon boarding, a vaccination
https://covid19.public.lu/en/travellers/vis
certificate, a certificate of recovery or the negative result of a nucleic acid amplification test (NAAT) for the detection of SARS-CoV-2 viral iting-luxembourg.html
RNA carried out less than 48 hours before the flight, or of a SARS-CoV-2 rapid antigen test carried out less than 24 hours before the flight.

MalawiAs from 1 June 2022, all travellers that are fully vaccinated will no longer be required to produce negative PCR tests. All travellers that are
https://www.malawitourism.com/travelnot fully vaccinated or don’t have a valid electronically verifiable COVID-19 full vaccination certificate will be required to produce aadvice/negative PCR based COVID-19 certificate that is not older than 72 hours at the time of arrival in the country.

Malaysia

Starting 1 May 2022, fully-vaccinated inbound travellers are no longer required to undergo pre-departure and on-arrival COVID-19 tests,
including children aged 12 and below as well as for those who have been infected with COVID-19 within six to 60 days before departure to https://www.malaysia.travel/travel-alert
Malaysia.

Maldives

Effective from March 13th, 2022, PCR is not mandatory to enter the Maldives.

https://immigration.gov.mv/faq-forvisiting-the-maldives/Mali

To enter Mali you will need proof of a “complete COVID vaccination” (i.e. usually at least two doses). If you do not have proof of acomplete vaccination, you need to present a negative COVID test (PCR) certificate less than 72 hours old.

https://www.gov.uk/foreign-traveladvice/mali/entry-requirements

Malta

As from 6th June 2022, persons aged 12 years and over are permitted to travel to Malta without undergoing quarantine as long as they
https://deputyprimeminister.gov.mt/en/h
provide either of the 3 documents mentioned below:1)Proof of full vaccination. 2) Proof of recovery from COVID-19. 3) Negative result to a ealth-promotion/covidpre-departure test.
19/Pages/travel.aspx

Mauritius

As from 1 July 2022, you no longer have to test or self-isolate to enjoy a Mauritius holiday.

https://mauritiusnow.com/mauritiustravel-advice/

MexicoTravelers are not required to provide proof of a negative COVID-19 test result before traveling to Mexico. Travelers who are connecting
through a different country on the way to Mexico should check the testing requirements of the country they are transiting through.

https://embamex.sre.gob.mx/eua/index.
php/en/2016-04-09-20-4051/tourism/1760-mexico-s-covid-19monitoring-system

MonacoAnyone aged 16 or over, whatever their nationality, who enters the Principality and comes from a foreign country classified in the green
zone must present:
1) Either the negative result of a PCR or antigen test of less than 24 hours
2) Or a complete vaccination;3) Or proof of a covid19 recovery certificate: positive PCR test older than 11 days and less than 6 months.

https://covid19.mc/en/travel/i-comefrom-abroad/

COVID-19 related restrictions for entry have been lifted. Negative COVID-19 PCR tests before and after arrival are no longer required.

https://www.gov.uk/foreign-traveladvice/mongolia/entryrequirements#entry-rules-in-responseto-coronavirus-covid-19

Mongolia

Montenegro

As of March 11, 2022 no proof of vaccination, COVID-19 passports/certificates or COVID-19 tests are required to enter Montenegro. (Last https://me.usembassy.gov/covid-19information/
updated: 06/13/22)
Travelers wishing to travel to Morocco, by any means, must present a health form, to be downloaded online before boarding, duly
completed. It is also distributed on board the airport or ship.
They must also present a valid vaccination passport or a negative PCR test result less than 72 hours old.
Children under the age of 12 are exempt from all requirements.

https://www.onda.ma/Je-suisPassager/Guide-du-voyageur/Newsa%C3%A9roportuaires-COVID19

Mozambique

PCR test is no longer needed to enter the country if a person presents a valid certificate showing proof of full vaccination against COVID19. In addition, children 11 and younger do not require a PCR test or proof of vaccination to enter the country.(Last updated: 06/13/2022)

https://mz.usembassy.gov/covid-19information/

Namibia

Fully vaccinated travelers are no longer required to produce a negative PCR test result upon arrival in Namibia but are instead required topresent an authentic, valid vaccination card at the port of entry. Travelers who are not fully vaccinated must produce a negative COVID19 Polymerase Chain Reaction (PCR) test result no older than 72 hours from their arrival in Namibia calculated from the date/time thesample was taken. The certificate must be issued by a certified laboratory to issue SARS-Co V-2 test results in the country of issuance.
(Last updated: 07/05/2022)

https://na.usembassy.gov/covid-19information/

Nepal

Effective March 10,2022, passengers entering Nepal from abroad by air or land must submit a certificate of full vaccination against
COVID-19.Passengers who fail to submit such certificate will have to submit the certificate with nagative report of COVIS-19 test(RTPCR,
True NAAT, Gene Xpert) within 72 hours of starting the journey.

https://www.immigration.gov.np/post/not
ice-5

MoroccoNertherlands

Niger

There are no coronavirus-related restrictions for entering the Netherlands for travellers who live in the EU/Schengen area or in a country
https://www.government.nl/topics/coronparticipating in the EU travel rules scheme. The EU entry ban applies to other travellers who live outside the EU/Schengen area, but there
avirus-covid-19/visiting-the-netherlandsare exemptions to the entry ban. For example, if you come from a safe country, or you have a proof of vaccination or proof of recovery
from-abroad/checklist-entry
that meets the requirements.

Travelers on arrival (disembarkation): For vaccinated travellers whose last dose is at least 4 weeks old, the COVID-19 PCR Test is nolonger required; For travellers who have not been vaccinated or who have not provided proof of vaccination whose last dose is at least 4
weeks old, the COVID-19 PCR Test is required.

Effective from 4th April 2022, as detailed below:
1)Fully vaccinated passengers arriving in Nigeria will not be required to carry out a pre-boarding COVID-19 PCR test nor carry out a Postarrival PCR test or Rapid Antigen Test upon arrival in Nigeria.
Nigeria2)Fully vaccinated passengers must show a verifiable full vaccination certificate otherwise, they will be treated as unvaccinated/partially
vaccinated under this protocol.
3)Unvaccinated and partially vaccinated passengers are required to take a COVID-19 PCR test 48hrs before departure and conduct days
2 and 7 post-arrival PCR tests. Such passengers will be expected to pay for their PCR tests through the NITP
Fully vaccinated travelers are not required to provide proof of a negative COVID-19 test result before traveling to Northern Macedonia. All
North
passengers coming from the medium- and high-risk countries must be in self-isolation for 14 days in their homes and to report to theMacedonia
authorities should they feel any symptoms.

https://www.gouv.ne/index.php/lescommuniques-du-gouvernement/296au-conseil-des-ministres-legouvernement-reitere-son-engagementa-remplacer-les-salles-de-classe-enpaillote-par-des-salles-de-classe-enmateriaux-definitifs

https://covid19.ncdc.gov.ng/advisory/https://koronavirus.gov.mk/en/seekhelp-or-report-irregularities/applicationfor-people-returning-from-travels

Norway

There are no longer special requirements for entry into Norway due to the corona situation. The same rules as before the corona
pandemic apply now.

Oman

https://www.omanairports.co.om/news/u
Non-citizen travelers aged 18 and above traveling to the Sultanate of Oman are required to present a vaccination certificate indicating that
pdate-on-travel-restrictions-related-tothey have received at least two doses of the approved COVID-19 vaccine at least 14 days before traveling.
covid-19/

Pakistan

PanamaVaccinated individuals do not require a pre-boarding negative PCR test. Unvaccinated individuals over age 12 must present a negative
PCR test taken within 72 hours.
Last update on April 6, 2022.Travelers will not have to present a negative COVID-19 test for entry as long as they can provide physical ordigital proof of at least 2 (two) doses or complete vaccination scheme endorsed by the WHO, EMA and FDA, equal to or greater than 14days after the last dose.

https://www.udi.no/en/corona/about-thecorona-situation/

https://pk.usembassy.gov/covid-19information/

https://www.tourismpanama.com/planyour-vacation/advisories/

Non-vaccinated or partially vaccinated travelers will be required to present a negative COVID-19 PCR or antigen test taken no more than
72 hours prior to their arrival time in Panama.

ParaguayPeru

https://www.migraciones.gov.py/index.p
Fully vaccinated travelers are not required to present a negative COVID-19 test result before traveling to Paraguay, in force as of April 19, hp/tramites/ingreso-y-salida-del2022.
pais/exigencias-sanitarias-vigentes-porcovid-19-para-el-ingreso-al-paraguay

Travelers with valid proof of being fully vaccinated are not required to have a negative COVID-19 test result before traveling to Peru.

https://busquedas.elperuano.pe/normas
legales/decreto-supremo-que-modificael-decreto-supremo-n-184-2020decreto-supremo-no-151-2021-pcm1988484-1/

Fully vaccinated travelers over the age of 18 who have received the primary series of COVID-19 vaccine and at least 1 COVID-19 booster
shot are not required to have a negative pre-departure COVID-19 test result before traveling to the Philippines. Travelers aged 12 to 17
https://www.philippineairlines.com/en/phPhilippines
who have received their primary COVID-19 vaccines are not required to have a negative pre-departure COVID-19 test result before/home/covid-19/arrivinginthephtraveling to the Philippines.(Last updated: 06/02/ 2022)

PolandFrom 28 March 2022, on the basis of the provisions of the Regulation of the Council of Ministers of 25 March 2022 on the establishmentof certain restrictions, orders and prohibitions in connection with the occurrence of the state of epidemic (Journal of Laws item 673), all
restrictions on travel to the Republic of Poland are abolished, which means that there is no longer an obligation to:- to present vaccination certificates when crossing the border,- performing tests for SARS-CoV-2,- the so-called arrival quarantine.

https://www.gov.pl/web/koronawirus/info
rmacje-dla-podrozujacych

Portugal

As of July 1, 2022, passengers entering national territory (including Azores and Madeira) are no longer required to present proof ofcarrying out a test to screen for SARS-CoV-2 infection with a negative result or to present a COVID-EU digital certificate or vaccination or
recovery certificate issued by third countries, accepted or recognized in Portugal.

https://www.visitportugal.com/en/node/446781

Romania

Saint Lucia

Visitors and residents arriving to Romania from any country in the world do not need to present proof of vaccination (complete scheme) ora negative RT-PCT test.(Last update: July 4, 2022)

Updated entry requirements effective 2 April 2022, There is no requirement for pre-travel test or quarantine for fully vaccinated travellers.
Fully vaccinated travellers must provide a valid vaccination record as requested on check in, for boarding and on entry to Saint Lucia.

https://romaniatourism.com/traveladvisory.html

https://www.stlucia.org/en/covid-19/

Saint
Vincent and Fully vaccinated travelers to St. Vincent and the Grenadines DO NOT NEED TO ARRIVE WITH A SARS-CoV-2 (COVID-19) TEST(Last
updated:06/15/2022)
theGrenadines

http://health.gov.vc/health/index.php/co
vid-19-protocols-documents

Health Minister Roberto Speranza has signed a new ordinance establishing, with effect from 1 March, the same rules for arrivals to Italy
from all non-European countries as those already in force for European countries. For entry to the national territory,

https://www.salute.gov.it/portale/nuovoc
oronavirus/dettaglioContenutiNuovoCor
onavirus.jsp?lingua=english&id=5412&a
rea=nuovoCoronavirus&menu=vuoto

San Marino

The requirements for entry into Sao Tome and Principe (STP) require passengers - of all nationalities - from the age of 12, who are not
Sao Tomewith the full digital vaccination certificate, to submit a negative antigen test, performed up to 48 hours before the date of travel. Those withand Principe
a valid digital certificate are exempt from the presentation of the antigen test.(Last updated: 05/06/2022)

https://portaldascomunidades.mne.gov.
pt/pt/vai-viajar/conselhos-aosviajantes/africa/sao-tome-e-principe

Saudi Arabia All precautionary and preventive measures related to combating corona pandemic are lifted.(Last updated: 06 March 2022)

https://www.moi.gov.sa/wps/portal/Hom
e/Home/dphome/!ut/p/z1/rVK5csIwEO35Cqeg9GiR
bCFKDYVtrgwQLjUe4QMriWUOD07PjKkSArwZMgWO7urfXvpIdGyrNZF0Nq

SenegalAll travelers to Senegal over the age of two years must present either a:1) COVID-19 vaccination certificate showing that they were fully vaccinated with AstraZeneca (SK Bioscience or Vaxzevria), Covishield,
Janssen J&J, Moderna, Pfizer-BioNTech, Sinovac, or Sinopharm at least 14 days before departure; or2)A negative COVID-19 PCR or RT-PCR test result issued at most 72 hours before departure. The test result must be in English or
French.( Last updated: 06/03/2022)
There are no restrictions on entering the Republic of Serbia.(Last updated 05/03/2022)

Serbia• All fully immunised visitors are exempted from pre-travel PCR test requirement upon presentation of their vaccination certificate.
• Unvaccinated or partially vaccinated visitors will be required to present a negative PCR test certificate from an accredited laboratory
Seychelles departure to Seychelles. Samples for this test must have been taken within 72hours before departure for PCR test and 24 hours for rapid
antigen test.(Last updated:03/15/ 2022)

https://sn.usembassy.gov/covid-19information/

https://www.mfa.gov.rs/en/citizens/travel-serbia/covid-19-entry-requirements
http://tourism.gov.sc/wpcontent/uploads/2022/03/SeychellesVisitor-Travel-Advisory-15-March-20221.pdf

Vaccinated passengers do not require a pre-departure or on arrival PCR test.
Unvaccinated or partially vaccinated passengers do not require a pre-departure PCR test. They do however require an on arrival PCR test https://www.gov.uk/foreign-traveladvice/sierra-leone/entrySierra Leone that should be booked and paid for in advance of departure through the Government of Sierra Leone travel portal.
requirements#entry-rules-in-responseto-coronavirus-covid-19

Singapore

Fully vaccinated travelers are not required to provide proof of a negative COVID-19 test result to enter Singapore.
If
you are Non-Fully Vaccinated Travellers and born before 2020 (i.e. above 2 years old) , take any of the following COVID-19 tests within 2 https://safetravel.ica.gov.sg/arriving/gendays before departure: COVID-19 Polymerase Chain Reaction test (PCR test) ; Antigen Rapid Test (ART)eral-travel/fully-vaccinated

Slovakia

From 6 April 2022, the Decree of the Public Health Authority of the Slovak Republic No. 28/2022 regulating the regime at the borders is
repealed. Thus, the obligation to register on eHranica as well as the mandatory quarantine for unvaccinated persons immediately after the https://www.mzv.sk/web/en/covid-19
arrival from abroad are abolished.

Slovenia

As of 14 May 2022, the RVT rule is no longer required.Free testing with a rapid antigen test and a rapid antigen test for self-testing isabolished. The government budget will only pay for testing with a rapid antigen test for activities where this is still required.

https://www.gov.si/en/topics/coronavirus-disease-covid-19/border-crossing/From 4 May 2022, All international travellers arriving at South African Ports of Entry must:(a) be vaccinated against COVID-19 and produce a valid vaccination certificate; or(b) produce a valid certificate of a negative PCR COVID-19 test, recognised by the World Health Organization, which was obtained not
more than 72 hours before the date of departure; or(c) produce a valid certificate of a negative antigen COVID-19 test performed by a medical practitioner, registered public health authority
South Africa or accredited/approved laboratory which was obtained not more than
48 hours before the date of departure; or(d) produce a valid certificate of a positive PCR COVID-19 test, recognised by the World Health Organization, for a test date less than 90days prior to the date of arrival and more than 10 days prior to the date of arrival, together with a signed letter from a health care provider,registered in the country of origin, stating that the person has fully recovered from COVID-19, is not experiencing any new symptoms andis fit to travel.

https://www.gov.za/covid-19/individualsand-households/travel-coronaviruscovid-19

Passengers arriving in Spain by AIR (except children under the age of 12 and passengers in international transit) from countries that DO
NOT belong to the European Union or are NOT considered Schengen associated countries, must have one of these documents:
1)DIGITAL COVID CERTIFICATE OR EU EQUIVALENT; 2)QR SPTH.

https://www.sanidad.gob.es/en/profesio
nales/saludPublica/ccayes/alertasActual/nCov/spth.htm

Spain

Sri Lanka

Sudan

Suriname

Fully Vaccinated travellers are exempted from pre-departure COVID-19 PCR/ Rapid Antigen tests from 1st March 2022. Not-Vaccinated &https://srilanka.travel/helloagain/
Not-fully vaccinated Travellers are released from On-arrival PCR test & Quarantine period.
The Sudanese Civil Aviation Authority requires all passengers entering Sudan to possess:
1) A COVID-19 vaccination certificate showing that the passenger is fully vaccinated at least 14 days and not more than 8 months before
arrival; or2) A negative polymerise chain reaction (PCR) test certificate taken not more than 72 hours before arrival; or3) A negative polymerise chain reaction (PCR) test certificate taken not more than 96 hours before arrival if arriving from Antigua andBarbuda, Argentina, Austria, Bahamas, Barbados, Belgium, Belize, Bolivia, Brazil, Bulgaria, Canada, Chile, China (People’s Rep.),
Colombia, Costa Rica, Croatia, Cuba, Cyprus, Czechia, Denmark, Dominica, Dominican Rep., Ecuador, El Salvador, Estonia, Finland,
France, Germany, Greece, Grenada, Guatemala, Guyana, Haiti, Honduras, Hungary, India, Ireland (Rep.), Italy, Jamaica, Latvia,
Lithuania, Luxembourg, Malta, Mexico, Netherlands, Nicaragua, Panama, Paraguay, Peru, Poland, Portugal, Romania, Slovakia,
Slovenia, Spain, St. Kitts and Nevis, Suriname, Sweden, Trinidad and. Tobago, USA, Uruguay or Venezuela.
4) Passengers 8 years old and younger are exempt.(Last Updated: 06/12/2022)

https://sd.usembassy.gov/covid-19information/

Persons who are fully vaccinated or can present a COVID-l9 recovery certifrcate not older than six (6) months and have stayed in Guyana https://www.flyslm.com/wpor French Guyana at least 14 days and are travelling to Suriname by land do not need to submit a Negative SARS-CoV-2 PCR or acontent/uploads/2022/04/SUR-COVIDnegative SARS-CoV-2 antigen test result.(Updated:04/13/2022)
19-Measures-13-April-2022.pdf

Sweden

Switzerland

Syria

COVID-19 travel restrictions have been lifted in Sweden. Providing proof of vaccination, recovery from COVID-19 or negative test results
is not required.

https://www.folkhalsomyndigheten.se/th
e-public-health-agency-ofsweden/communicable-diseasecontrol/covid-19/recommendations-forthose-travelling/

There are currently no entry restrictions due to the COVID-19 pandemic. No proof of vaccination, recovery or testing is required for entry
into Switzerland.

https://www.bag.admin.ch/bag/en/home/krankheiten/ausbrueche-epidemienpandemien/aktuelle-ausbruecheepidemien/novel-cov/empfehlungenfuer-reisende/quarantaeneeinreisende.html#-924144951

If you’re fully vaccinated, you can enter Syria without needing to test but you may be required to isolate.If you’re not fully vaccinated, you’ll https://www.gov.uk/foreign-travelneed to show proof of a negative PCR test (taken no more than 72 hours before entry) when entering Syria.(Last updated:05/28/2022)
advice/syria/entry-requirements

Tajikistan

Each traveler aged three years and older must present either
1) a COVID-19 vaccination certificate showing that they are fully vaccinated or2) results from a negative COVID-19 PCR test issued within 72 hours of arrival.
Test results are verified before passengers are allowed to board flights to Dushanbe and again upon arrival in Dushanbe.
(Last updated: 06/28/2022)

https://tj.usembassy.gov/covid-19information/

Thailand

From 1 July, 2022, foreign nationals are only required to show proof of either a certificate of vaccination or a negative RT-PCR or
professional ATK test result within 72 hours of travel.

https://www.tatnews.org/

For fully vaccinated travellers arriving in Togo, PCR test is no longer required and will not be performed upon arrival either.
For unvaccinated travellers arriving in Togo, proof of a negative PCR test is still required and these passengers will be subjected to a
PCR test at arrival.The validity of the PCR test results is 5 days.(Date last modified: 15/04/2022)

https://voyage.gouv.tg/?language=en#p2

Togo

Trinidad
Effective 1st July, 2022, COVID-19 PCR or Lab Acquired Antigen Test results will No Longer be required for entry into Trinidad andand Tobago Tobago.
The 05-day self-confinement rule is no longer required for foreign visitors over the age of 18 who are not vaccinated or who have notcompleted their vaccination schedule.
Tunisia
However, they are still compelled to present a negative result of a PCR test carried out 48 hours before boarding or of a 24-hour rapid test
prior arriving on Tunisian territory..(Updated 27th May 2022)

https://health.gov.tt/preparation-forentry

https://www.discovertunisia.com/en/infos-pratiques/entry-requirements

TurkeyA PCR test is required for individuals over the age of 12 years old who are unable to show proof of vaccination or are unable to submit adocument stating that they have had the virus within the last 6 months.(Last Updated: 06/132022)

https://tr.usembassy.gov/covid-19information-2/

UgandaIf you are fully vaccinated (and for children under the age of 6) you are now able to enter Uganda via air and land border points without
showing a negative COVID-19 PCR certificate. You will be required to show evidence that you are fully vaccinated.
If https://www.gov.uk/foreign-travelyou are not fully vaccinated you will need to show a negative COVID-19 PCR certificate issued no more than 72 hours before departure on advice/uganda/entryrequirements#entry-rules-in-responsearrival by land or air.
to-coronavirus-covid-19

From 26 February 2022,Those coming to the UAE have to make sure to present an approved QR code- accompanied Covid-19
United Arab vaccination certificate containing a QR code; unvaccinated travelers have to present an approved negative PCR test result received within https://covid19.ncema.gov.ae/en/News/
Details/2316
Emirates 48 hours, or a QR code-accompanied certificate of recovery from a Covid-19 infection obtained within one month from the date of travel.
Travelers from the UAE have to follow the requirements of medical examinations and vaccinations in place in their countries of destination.
UnitedKingdom

From 4am 18 March,2022, no-one entering the UK will need to take tests or complete a passenger locator form.

UnitedFully vaccinated travelers are exempt from testing requirements. Travelers will be required to present a valid vaccination certificate with
Republic of
QR code for verification upon arrival.(Last updated on :06/27/2022).
Tanzania
As of 12:01AM ET on June 12, 2022, CDC will no longer require air passengers traveling from a foreign country to the United States toshow a negative COVID-19 viral test or documentation of recovery from COVID-19 before they board their flight. (Last updated onUnited States :06/13/2022)

Uruguay

Foreign citizens who are fully vaccinated or have already completed the COVID-19 disease within the last 90 (ninety) days are notrequired to present a negative COVID-19 RT-PCR or antigen test result before departure to Uruguay.Unvaccinated travelers need toprove a negative result of SARS-CoV-2 virus detection test (by molecular biology technique PCR-RT or antigen test), performed no morethan 72 (seventy-two) hours before the start of the trip, in a laboratory enabled in the country of origin or transit.

https://www.gov.uk/government/news/all-covid-19-travel-restrictions-removed-inthe-uk
https://tz.usembassy.gov/covid-19information/

https://www.cdc.gov/coronavirus/2019ncov/travelers/noncitizens-US-airtravel.html
https://www.gub.uy/ministerio-saludpublica/comunicacion/publicaciones/req
uisitos-para-ingreso-uruguay-personasnacionales-extranjeras

Effective June 10, 2022, COVID testing or proof of vaccination are no longer required to enter Uzbekistan at any air, rail or land entry point.
https://uz.usembassy.gov/covid-19Uzbekistan (Last updated: 06/13/2022)
information/
Effective May 30, 2022, all air passengers entering Venezuela must present a certificate of vaccination against COVID-19 (completed
vaccination schedule) in either physical or digital format (with QR code), with the last dose administered at least 14 days prior to the entry
date in Venezuela. If more than 270 days has passed since the last dose of a completed vaccination schedule, proof of a booster dose isrequired. In lieu of proof of vaccination, passengers must present a negative PCR-RT COVID-19 test result, taken within 72 hours ofarriving. (Last updated: 06/21/2022)

https://ve.usembassy.gov/covid-19information/

Viet Nam

Foreign arrivals will no longer have to take any COVID-19 tests to enter Viet Nam from May 15, 2022, the Government announced Friday.

https://en.baochinhphu.vn/viet-nam-toscrap-covid-19-test-requirements-forvaccinated-entrants-from-mid-may11122051320312898.htm

Zambiahttps://www.zambiaimmigration.gov.zm/
Fully vaccinated traveller do not require any form of negative COVID test results, but shall be requires to provide proof of a full vaccination wpstatus.(Updated:03/23/2022)
content/uploads/2022/03/Revised_Trav
el_Guidelines_Zambia.pdf

Zimbabwe

All ports of entry have been opened. Returning residents & visitors will no longer be required to present a negative COVID19 PCR
certificate at the port of entry but should present a valid Vaccination Certificate showing they are fully vaccinated.

Venezuela

https://zimbabwetourism.net/covid19guidelines-for-travellers/Reopen for International Travel With Required COVID-19 Testing (29 Member States)
Updated on 19 July, 2022
AngolaBurundiChile

Anyone arriving in Angola must present proof of a negative RT-PCR COVID-19 test; passengers may take the test up to 72 hours
prior to travel.(Last updated: 06/14/2022)
All travellers are required the negative COVID-19 test(PCR and/or serology) for entry. The test must be done within 72 hours ofboarding a plane to Bujumbura. All travelers must take a COVID-19 test upon arrival. The cost is $100.
(Last updated: 06/13/2022)
While it is not mandatory, it is always advisable to perform a diagnostic test before traveling.The approval of vaccines to access the
Mobility Pass is voluntary. We recommend processing it, since the pass allows you to enter interior rooms of restaurants, cinemas,
theaters, bus trips, among others.

https://ao.usembassy.gov/covid-19information/
https://bi.usembassy.gov/covid-19information/
https://www.chile.travel/planviajarachil
e/

Congo

If you are a traveler to Congo, you must before your departure from abroad: Pay for the COVID-19 PCR test to be carried out assoon as you arrive at Congo airports (Brazzaville and Pointe Noire).

https://voyage-congo.com/en/

Democratic
Republic ofCongo

If you’re fully vaccinated, Travellers aged 11 and above need to provide proof of a negative coronavirus test upon entry to DRC
and/or proof of vaccination against COVID-19. The test result date must be within the 48 hours prior to your arrival. Children under
the age of 11 are exempt. There is no requirement for a PCR COVID-19 test at the airport upon arrival.If you’re not fully
vaccinated,you will be subject to an additional PCR test on arrival.

https://www.gov.uk/foreign-traveladvice/democratic-republic-of-thecongo/entry-requirements

Djibouti

Even if you are fully vaccinated you will still need to arrive with a PCR test which must have been taken within 72 hours of the startof the journey and 120 hours of arrival in Djibouti. On arrival you will be required to take an additional COVID-19 test at the airport
for which you will pay $30.

https://www.gov.uk/foreign-traveladvice/djibouti/entryrequirements#entry-rules-inresponse-to-coronavirus-covid-19

EcuadorAny traveler over 3 years of age must present a mandatory vaccination certificate with QR code or COVID-19 vaccination card
valid with at least 14 days of validity after completing the scheme, or the negative result of an RT-PCR test carried out up to 72
hours prior to boarding to Ecuador. Passengers under 3 years of age will not present these requirements.

https://www.aeropuertoquito.aero/es/p
rotocolo-covid-19.html

EritreaTravellers, regardless of whether fully vaccinated or not, must have a negative COVID-19 PCR test result. The test must be taken
a maximum of 72 hours before arrival in Eritrea.(Last updated: 05/09/2022)

https://er.usembassy.gov/covid-19information/

Fiji

Fiji is quarantine free for fully-vaccinated travellers from all over the world. Travellers (16yrs+) must produce a digital/paper
certification of full-vaccination at least 14 days before travel. All travellers (12 years+) must take a pre-booked Rapid Antigen Test
(RAT) anytime within 72 hours of arrival in Fiji, at their hotel or nearby testing facility. This test must also be taken by travellers
transiting Fiji for more than 48 hours

https://www.fiji.travel/articles/frequentl
y-asked-questions-travelling-to-fiji

From November 1, 2021, the following COVID 19 measures shall apply as travel requirements for entry into Guyana. The
measures in the Official Gazette (Extraordinary) of Guyana, 235/2021 is applicable with these variations.
The following documents are required before travelling to Guyana
1) Proof of full vaccination
2) Negative SARS-CoV-2 Antigen test not older than 72 hours or a negative SARs-Cov-2 PCR test not older than 72 hours

https://www.health.gov.gy/images/trav
el_requirement.pdf

Guyanahttps://caa.gov.ir/covidforms?_gl=1*1ik8cy7*_ga_0NMZLXT
Z77*MTY0NjM1OTE5NS40LjEuMTY0
NjM1OTI3MS4w

Iran

Travelers must have a negative COVID-19 PCR test result. The test must be taken a maximum of 72 hours before departure. The
results must be in English or approved by an Iranian consulate.

Japan

All entrants must present a certificate of inspection within 72 hours before leaving their country. Test method is valid only for one of
the following.
1)Nucleic Acid Amplification Test
2)PCR (Polymerase Chain Reaction)3)LAMP (Loop-mediated Isothermal Amplification)
https://www.mhlw.go.jp/stf/covid4)TMA (Transcription Mediated Amplification)
19/border_test.html
5)TRC (Transcription Reverse-transcription Concerted reaction)6)Smart Amp (Smart Amplification process)7)NEAR (Nicking Enzyme Amplification Reaction)8)Next Generation Sequence

Liberia

Travelers must have a negative COVID-19 PCR test result from a test taken a maximum of 72 hours before departure andobtained from an accredited laboratory.(Updaed:04/21/2022)

https://www.nphil.gov.lr/index.php/libe
ria-health-ministry-introduces-newcovid-19-protocols-for-travelers/

Libya

A COVID-19 PCR test administered no more than 48 hours prior to travel to Libya is required.(Last updated: 05/10/2022)

https://ly.usembassy.gov/u-s-citizenservices/covid-19-information/

Madagascar

Entry requirements update, May 12, 2022:Presentation of a negative result of an Rt-PCR test performed 72 hours before
boarding.Performing a rapid antigen test upon arrival in Madagascar, at the traveler’s expense. In case of a positive result to therapid antigen test on arrival, a 7-day self-isolation at least will be implemented in a dedicated facility, at the traveler’s expense.

https://madagascar-tourisme.com/Frfr/border-reopening/

Mauritania

A NEGATIVE PCR TEST IS ONLY REQUIRED FOR ENTRY TO MAURITANIA IF YOU LACK PROOF OF FULL VACCINATION.
Fully vaccinated persons are still require to present a negative PCR test result by airlines prior to boarding for Mauritania boundflights. (Last updated: 06/13/22)

https://mr.usembassy.gov/covid-19information-2/

MyanmarAll foreign nationals are required to present laboratory evidence of a negative COVID-19 RT-PCR test issued at most 48 hours
before arrival if you are unable to present a COVID-19 fully vaccinated certificate at least 14 days before arrival to Myanmar with
one of the vaccines approved by the Ministry of Health (MOH)l.(Last updated: 06/17/2022)

https://mm.usembassy.gov/covid-19information/

Lastest updated: 21 June 2022:
1)You do not need a pre-departure test to enter New Zealand.
New Zealand2) Most travellers need to be vaccinated and take 2 rapid antigen tests (RATs) after arriving in New Zealand.

Nicaragua

Travelers must have an original negative COVID-19 RT-PCR test result. The test must be taken a maximum of 72 hours before
arrival in Nicaragua.

https://covid19.govt.nz/internationa
l-travel/travel-to-new-zealand/predeparture-tests-to-enter-newzealand/
https://www.intur.gob.ni/2020/09/21/ni
caragua-reanuda-vuelos-comerciales/

PalauTravelers must submit proof of complete COVID-19 vaccination with final dose administered at least fourteen (14) days prior to
departure to the Republic.All Travelers must also provide proof of either: a). A negative result of a COVID-19 PCR test (any type of
PCR test, including NAAT, RTPCR, qPCR, RT-LAMP, TMA, molecular test, isothermal amplification, ddPCR, or CRISPR), andsuch test must be taken within three (3) days prior to departure from the point of origin to the Republic; or b). A negative result of a
https://www.palaugov.pw/travel/
COVID-19 antigen test (WHO or US FDA authorized or approved test), and such test must be taken within one (1) day prior to
departure from the point of origin to the Republic; or c). Documentation of recovery from COVID-19 which includes proof of a
recent positive viral test and a letter from a healthcare provider or a public health official stating that traveler has recovered fromCOVID-19 and is cleared to travel.

Papua New
Guinea1) All persons must be fully vaccinated to travel to PNG, unless they are under 18 years of age or are a citizen of Papua New
Guinea. A person is considered fully vaccinated if they have had the recommended number of doses for the vaccine as listed in
Schedule 2, within the past 6 months; or they have had the recommended number of doses for the vaccine, as listed in Schedule 2 https://www.papuanewguinea.travel/tr
and they have had a booster vaccine; 2) All persons traveling to PNG must have a valid COVID-19 test within 72 hours prior toavel-advice-update
their original port of departure. Children aged 5 years and under are exempted from being tested; 3)All people arriving into PNG will
be tested for COVID-19 upon arrival;

Qatar

Travelers who are required to have a PCR lab result before traveling to Qatar must have it at a medical center authorized by the
https://covid19.moph.gov.qa/EN/travel
health authorities in the country of departure. A negative test result is required and must be obtained no more than 48 hours before-and-return-policy/Pages/default.aspx
the time of departure from the country of origin. (Please see the pre-travel test rules for detailed guidance.)

Republic of
Korea

All passengers arriving in the ROK by plane must provide proof of a negative COVID-19 PCR test taken within 48 hours of theirdeparture.Arriving passengers will experience some combination of temperature screening, health questionnaires, quarantines,
and/or COVID-tests, depending on points of departure, visa status, and nationality.(Updated:05/11/2022)

https://kr.usembassy.gov/022420covid-19-information/

RussiaFederation

The Russian government requires that all foreign travelers present a negative PCR COVID-19 test result upon arrival, dated nolater than two days prior to arrival in Russia. The results can be in English and/or digital. (Last updated:03/30/2022)

https://ru.usembassy.gov/covid-19information/

RwandaAs part of Government measures to prevent the spread of COVID-19, the following is mandatory upon entry into Rwanda, effective
14th May 2022:
Arriving passengers at Kigali International Airport must present a negative Antigen Rapid Test (RDT) taken 72 hours prior to
departure (meaning travelers must be tested and get results within 3 days of their first flight). COVID-19 Test is not mandatory foraccompanied children under 5 years. Incoming travelers eligible (aged 12 years and above) for Covid-19 vaccine are encouraged
to be fully vaccinated before their travel. An additional Antigen Rapid Test (RDT) will be taken upon arrival at own cost.

https://www.rbc.gov.rw/index.php?id=745

Saint Kitts
and Nevis

Effective Friday April 1st 2022, all travelers must submit a Rapid Antigen negative test result from a CLIA/CDC/UKAS approved lab
accredited with ISO/IEO 17025 standard, taken 1 day prior of your arrival or submit a COVID-19 RT-PCR or NAAT negative test
https://www.stkittstourism.kn/travelresult from a CLIA/CDC/UKAS approved lab accredited with ISO/IEO 17025 standard, taken within 3 days of your arrival, alongrequirementswith the required embarkation form, and all other supporting documentation. An embarkation form is required regardless of age.

1) Per guidance issued on July 25, 2021, by the Ministry of Health in the Republic of South Sudan, travelers must present a valid
SARS-CoV2 PCR negative test certificate with a sample collected not more than 72 hours prior to arrival at the point of entry andhttps://ss.usembassy.gov/covid-19South Sudan with documentation of full COVID-19 vaccinations (completed at least two weeks before traveling) to not require a quarantine
information/
period. 2) Per guidance issued on December 22, 2021, by the Ministry of Health in the Republic of South Sudan, both inbound andoutbound travelers must present both a negative PCR test and proof of vaccination.(Last updated: 06/13/2022)

Vaccination Report – 19 July 2022
1. Vaccine Implementation

1WHO’s Emergency Use Listing(EUL) Vaccines (Last Updated 7 July 2022）
Manufacturer

Name of Vaccine

NRA of Record

Vaccine type

Pfizer-BioNTech(US)

BNT162b2/COMIRNATY
Tozinameran (INN)

EMA,USFDAmRNA

AZD1222 Vaxzevria

EMA,
MFDS KOREA,
Japan MHLW/PMDA,
Australia TGA,
COFEPRIS(Mexico),
ANMAT(Argentina)

Non ReplicatingViral
vector

DCGI

Non Replicating Viral
Vector2

AstraZeneca(UK)

3

Serum Institute of India(India)4

Johnson &Johnson(US)

Ad26.CoV2.S

EMA, DCGINon ReplicatingViral
vector5Moderna(US)

mRNA-1273

EMA, USFDA, MFDS

mRNA

6

Sinopharm Beijing(China)SARS-CoV-2
Vaccine(Vero Cells)

NMPA

Inactivated virus(Vero Cells)

7

Sinovac(China)COVID-19 Vaccine(Vero Cells)

NMPA

Inactivated virus(Vero Cell)

8

Bharat Biotech(India)SARS-CoV-2 Vaccine,
Inactivated (Vero Cell)/
COVAXIN

DCGI

Whole-Virion Inactivated(Vero Cell)

Serum Institute of India(India)NOVAVAX(US)CanSinoBIO(China)

9
10
11



Covishield(ChAdOx1_nCoV-19)

DCGI

NVX-CoV2373/Covovax

Protein Subunit

EMA

NVX-CoV2373/Covovax

Protein Subunit

NMPA

Ad5-nCoVNon ReplicatingViral
vector

40 Vaccines Approved by at Least One Country
VaccineTypemRNA

Non Replicating
Viral vector

Inactivatedvirus

Protein
SubunitDNA

Virus-like
Particles
(VLP)

Total

In Use

4

7

11

16

1

1

40

Source: https://covid19.trackvaccines.org/vaccines/ （Last Updated 18 July 2022）

Vaccination against COVID-19 has now started in 218 locations

(Source: Our World in Data. Last Updated 18 July 2022)
Location
Worldwide

Doses Given
12.23 billion

Complete Initial Protocol(% of population)
4.85 billion(61.28 %)Partly Vaccinated(% of population)
5.28 billion(66.75 %)About this data:
a: This data changes rapidly and might not reflect doses still being reported. It may differ from other sites & sources.
b: Where data for full vaccinations is available, it shows how many people have received at least 1 dose and how
many people have been fully vaccinated (which may require more than 1 dose).Where data for full vaccinations isn't
available, the data shows the total number of vaccine doses given to people. Since some vaccines require more than
1 dose, the number of fully vaccinated people is likely lower.
c: It only has full vaccination totals in some locations.

2. Effectiveness of Vaccine and/or Previous Infection against symptomatic
infection for Alpha, Delta and Omicron variants
Vaccine Status
Alpha
1 Dose (BNT162b2 or
ChAdOx1 nCoV-19)
1 Dose (mRNA-1273)
1 Dose(Sinopharm or Sinovac)

2 Doses (BNT162b2)

48.7% (95%CI: 45.5-51.7%)1
66%(BNT162b2)4
64% (ChAdOx1)4
83%4

93.7% (95%CI: 91.6-95.3)1
76% (95%CI: 69-81%)2
89% 4

Vaccine Effectiveness
Delta
30.7% (95%CI: 25.2-35.7%)1
56%(BNT162b2)467%(ChAdOx1)4
82% (95% CI:73- 91%) 7
72%4
13.8%,(95%CI: -60.2-54.8%)3
88% (95%CI: 85.3-90.1%)1
42% (95% CI: 13-62%)2
87%4
93%(95% CI: 88-97%/12-18Y)5
93% (95% CI: 88-97%)7

Omicron50% (95% CI: 35%–62%)8

2 Doses (ChAdOx1 nCoV-19)

2 Doses (mRNA-1273)

74.5% (95%CI: 68.4-79.4%)1

86%, (95%CI: 81-90.6%)2

67.0% (95%CI: 61.3-71.8%)1

76%, (95% CI: 58-87%)2

2 Doses(Sinopharm or
Sinovac)59.0%, (95%CI: 16.0-81.6%)3

3 Doses (BNT162b2)

95.33% (SD 6.44)6
86.1% (95% CI, 67.3 to 94.1)11

3 Doses(mRNA-1273)
2 Doses (BNT162b2) +1Dose(mRNA-1273)
2 Doses(ChAdOx1 nCoV19)+1Dose(BNT162b2)
2 Doses (ChAdOx1 nCoV-19)+
1Dose (mRNA-1273)

30.4% (95% CI: 5.0%-49.0%)9

67.2% (95% CI: 66.5- 67.8%) at 2
to 4 weeks10
49.4% (95% CI, 47.1 to 51.6)11
52.2% (95% CI, 48.1 to 55.9)12
62.5% (95% CI: 56.2-67.9%)9
47.3% (95% CI, 40.7 to 53.3)11
73.9% (95% CI: 73.1- 74.6%) at 2
to 4 weeks10
62.4% (95% CI, 61.8- 63.0) at 2 to
4 weeks10
70.1% (95% CI, 69.5 to 70.7) at 2
to 4 weeks10

2 Doses (BNT162b2)+Previous infection

55.1% (95% CI, 50.9 to 58.9)12

3 Doses (BNT162b2)+Previous infection

77.3% (95% CI, 72.4 to 81.4)12
76.1% on BA.4 or BA.5

Previous Omicron Infection(95% CI: 54.9 to 87.3%)13

References:
1) Effectiveness of Covid-19 Vaccines against the B.1.617.2 (Delta) Variant2) Comparison of two highly-effective mRNA vaccines for COVID-19 during periods of Alphaand Delta variant prevalence3) Efficacy of inactivated SARS-CoV-2 vaccines against the Delta variant infection in
Guangzhou: A test-negative case-control real-world study4) Effectiveness of COVID-19 vaccines against variants of concern in Ontario, Canada
5) Effectiveness of BNT162b2 Vaccine against Delta Variant in Adolescents
6) A RCT of a third dose CoronaVac or BNT162b2 vaccine in adults with two dosesof CoronaVac
7) Effectiveness of BNT162b2 Vaccine against Delta Variant in Adolescents
8) Effectiveness of BNT162b2 Vaccine against Omicron Variant in South Africa
9) Effectiveness of mRNA-1273 against SARS-CoV-2 omicron and delta variants10) Covid-19 Vaccine Effectiveness against the Omicron (B.1.1.529) Variant11) Effect of mRNA Vaccine Boosters against SARS-CoV-2 Omicron Infection in Qatar
12) Effects of Previous Infection and Vaccination on Symptomatic Omicron Infections
13) Protection of SARS-CoV-2 natural infection against reinfection with the BA.4 or BA.5
Omicron subvariants

3. Latest Relevant Articles


Effectiveness of a fourth dose of mRNA COVID-19 vaccine against all-cause
mortality in long-term care facility residents and in the oldest old: A nationwide,
retrospective cohort study in Sweden (Published: July 13, 2022)



Immune boosting by B.1.1.529 (Omicron) depends on previous SARS-CoV-2
exposure (Published 14 Jun 2022)



Neutralizing antibody activity against 21 SARS-CoV-2 variants in older adults
vaccinated with BNT162b2(Published: 14 July 2022)

Maternal Vaccination and Risk of Hospitalization for Covid-19 among
Infants(Published: 14 July 2022)



SARS-CoV-2 Variant Vaccine Boosters Trial: Preliminary Analyses(Posted on June15, 2022)



Novavax NVX-COV2373 triggers potent neutralization of Omicron sub-lineages(Posted on July 17, 2022)

4. Other Information

FDA Authorizes Emergency Use of Novavax COVID-19 Vaccine (July 13, 2022)

UK Covid-19 vaccine boosters to be expanded to all over-50s this autumn.(July
15,2022)

ECDC: Preliminary public health considerations for COVID-19 vaccination
strategies in the second half of 2022(July 18, 2022)



CDC: Rates of COVID-19 Cases and Deaths by Vaccination Status (July,2022)

w

TECHNICAL REPORT

Preliminary public health considerations for
COVID-19 vaccination strategies in thesecond half of 2022
18 July 2022

Key messages
•

•

•

•

•

•

In the current post-acute phase of the pandemic, the introduction and emergence of new SARS-CoV-2 variants
with increased transmissibility and/or immune escape capacity, together with waning protection against
infection and severe disease from natural or vaccine-induced immunity, can result in new waves of virustransmission and surges of COVID-19 cases with a subsequent rise in hospitalisations, ICU admissions and deaths.
As of 10 July 2022, the overall notification rates of COVID-19 cases in the EU/EEA remain high and have been
increasing for the past five weeks. Case rates among people aged 65 years and over increased in 23 of the 27
reporting countries. These increases are still relatively recent, and they signal the start of a widespread wave
driven by the BA.4 and BA.5 variants of concern.
As of 3 July 2022, based on GISAID or the European Surveillance System (TESSy) data, Omicron BA.4 or BA.5
are the dominant circulating SARS-CoV-2 variants (>50%) in 18 EU/EEA countries, and, based on projections,the proportion of all COVID-19 cases due to infection with BA.4 or BA.5 will exceed 95% in most EU/EEA
countries by end-July 2022.
The increasing transmission among older age groups is starting to translate into severe disease, and, as of 10
July 2022, 12 countries reported an increasing trend in either hospital or ICU admissions/occupancy comparedwith the previous week. At the same time, even though the EU/EEA death rate has remained stable for the last
five weeks, the forecast for the period up to 31 July indicates that both case notification rates and death rates
will increase.
As of 10 July 2022, the cumulative uptake of the primary COVID-19 vaccination course in the total population in
the EU/EEA reached 72.8%, and 52.9% for the first booster dose. Among individuals aged 60 years and older,vaccine uptake is higher, 90.8% and 83.1% for the primary course and the first booster respectively, but stillwith significant disparities across EU/EEA countries.
Currently, 20 countries recommend the administration of a second booster dose, mostly for age groups from60+ to 80+ years and for long-term care facility (LTCF) residents, with a time interval after the first booster
dose varying between three to five months. Approximately 16.5 million second booster doses have been
administered so far (data reported to TESSy by 21 countries), the majority among those 60+ (88%), and with a
median uptake of 11.6% among 60+ (range: <0.1-59.5%) and 20% among 80+ (range: 0.1-80.1%).

Suggested citation: Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022. 18 July 2022.
Stockholm: ECDC; 2022
© European Centre for Disease Prevention and Control. Stockholm, 2022.

ECDC TECHNICAL REPORT

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Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

Published literature indicates that vaccine effectiveness (VE) against severe outcomes caused by Omicron
remains high, including among older age groups, with continued strong protection generally around 80−90%
around two to three months after receiving the first booster, albeit with the balance of evidence indicating
gradual waning after three to six months (VE estimates in the range 53-100%). A second mRNA booster dose
restores VE against severe disease, which remains stable for up to 10 weeks, but longer follow-up times are not
yet available. Only limited data are available on VE against Omicron sub-lineages BA.4 and BA.5. A preliminary
analysis from Portugal suggests that the VE may be reduced against infection with BA.5 as compared to
infection with BA.2, while data from South Africa indicate that high VE against severe disease has been
maintained during the BA.4/BA.5 dominant period.
The analysis of severe outcomes of disease among COVID-19 cases having received a first booster dose (TESSydata) shows that hospitalisation and death are rare in this group (0.6% and 0.1% respectively); nevertheless,the adjusted risk of hospitalisation and death is higher in those who received the first booster dose more than
three months previously, older age groups (80+ and 60 to 79) and males.
Mathematical modelling shows that for countries with an uptake of >40% for the first booster in the whole
population, a second booster rollout among 60+ can have a substantial impact on restoring vaccine-induced
protection against hospitalisation in this population from mid-July to the end of 2022, with an expected medianabsolute increase of 17% (95% UI 6-34%) on 1 November 2022. For countries with an uptake of <40% for the
first booster in the whole population, closing the vaccination coverage gaps of the primary series and the first
booster has a larger overall effect than a second booster rollout, with an expected median absolute increase of
population-level vaccine-induced protection against hospitalisation of 16% (95% UI 10-41%) and 5% (95% UI
1-24%) on 1 November 2022, respectively. Furthermore, an earlier second booster rollout among 60+ in midJuly 2022 results in a larger vaccine-induced protection against hospitalisation for the rest of 2022 compared toa later second booster rollout. The benefit in terms of vaccine-induced protection against hospitalisation in the
population 60+ decreases the more the starting date of the second booster rollout is moved later (we evaluate
a starting date in July, August, September, or October).

Public health considerations
Considering the above, the following public health considerations provide some guidance for vaccination strategies
and the use of additional booster doses of mRNA vaccines in the second half of 2022:
•
•
•

•
•

•

•

At this stage of the pandemic, the objective of COVID-19 vaccination campaigns continues to be to reduce
COVID-19 hospitalisation, severe disease and death, and to protect health systems.
Improving vaccine uptake of the primary course and first booster dose in eligible individuals who are yet toreceive them remains a priority, especially for population groups at higher risk of severe outcomes and forcountries with lower uptake of primary course and first booster dose.
An early second booster rollout, not only among 80+, but also for adults between the ages of 60 and 79 years
and individuals with underlying comorbidities regardless of age, should now be considered to prevent severe
disease and safeguard health system capacity, and countries should consider a rapid deployment. This would
be particularly relevant and impactful in countries where the BA.4/BA.5 wave is starting or has not yet peaked.
Second boosters could be administered at least four months after the previous one, with a focus on people who
received a previous booster more than six months ago.
At the moment, for immunocompetent individuals below 60 years of age, unless they have underlying
comorbidities, there is no clear epidemiological evidence to support the administration of a second booster.
The early administration of a second booster dose with currently available vaccines to healthcare workers(HCW) and personnel working in LTCFs for infection control purpose, is likely to offer only modest benefits interms of limiting the risks of transmission to vulnerable people in their care, and be of limited duration. HCW
and LTCF personnel may receive a second booster for their own protection if they belong to any prioritised
population group based on age or underlying comorbidities. It should be ensured that LTCF residents receive
the recommended booster doses; non-pharmaceutical interventions (NPIs) in healthcare settings including
LTCFs remain effective measures to protect vulnerable individuals; and access to therapeutics is an additional
key measure for the protection of LTCF residents from severe outcomes.
In addition, in anticipation of further waves of infection that may arrive in the autumn/winter season, countries
should consider the need for rollout of further additional booster doses of mRNA vaccines for population groups
at risk of severe disease (e.g. 60+,individuals with underlying comorbidities, immunocompromised individuals
and pregnant women) later in the year, possibly combining campaigns for vaccination against COVID-19 andinfluenza, taking into account any new evidence available at that time on the benefit/risk profile of repeatedboosters and the impact on the capacity of health systems to deliver vaccinations in the context of othercompeting public health priorities in the post-pandemic phase.
The boosting of HCW and LTCF personnel should also be considered for this later rollout. If adapted, vaccines
will show increased neutralisation against Omicron variants, indicating a possible higher effect against infection
and transmission, they may be used to provide both direct and indirect protection.

2

ECDC TECHNICAL REPORT

•
•

•

•

Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

The need for, and optimal timing of further additional booster doses in autumn/winter may vary acrosscountries, especially depending on the timing of rollout of second boosters in spring/summer 2022 andemerging evidence of continued protection against severe disease in those that have received a second booster dose.
Updated Omicron-adapted vaccines will likely be authorised for use in the EU in September and possibly
available sometime during the last trimester of 2022, however the distribution timeline and available supplies
are currently being defined with manufacturers. Nevertheless, it is important to continue the efforts to increasevaccination rates with available vaccines for groups at high risk of severe disease in a timely manner, and not to
wait for the new Omicron-adapted vaccines.
Future vaccination strategies may also differ depending on the availability of the updated vaccines and theircharacteristics. Countries may have to use different types of vaccines for different strategies and populationgroups depending on the characteristics of the updated vaccines compared to first-generation ones andconsidering emergence of new variants.
Communication initiatives to promote uptake of additional vaccine doses, and to promote completion of the
primary series by those who have not yet done so face recurring and emerging challenges. These include
complacency towards the threat of COVID-19, the need to provide evidence-based reassurances to address
lower confidence in vaccine effectiveness and concerns about side effects, as well as potential confusion in the
public as to how boosters will be offered in the coming months, timelines for adapted vaccines, who should
receive these and when. This context stresses the importance of understanding and addressing individuals’ andcommunities’ beliefs, concerns and expectations regarding the vaccine and the disease. Clear information
should be provided around the rationale for recommendations, and the benefits of the primary course andboosters for different population groups, including for those who already had the disease.

These public health considerations are based on current scientific evidence and epidemiological trends, and will be
periodically reassessed. The scope of these considerations is focused on the second half of 2022, with an emphasison the case for booster vaccination and closing the primary vaccination gap in the late summer/early autumn, andnot for longer term COVID-19 vaccination strategies. National Immunisation Technical Advisory Groups (NITAGs)
will ultimately make national decisions on the use of COVID-19 vaccines, taking into account the previous
vaccination uptake and the epidemiological situation in their countries.

Background and rationale
Over half of the European Union/European Economic Area (EU/EEA) countries are already recommending and rolling out
second booster doses of COVID-19 vaccines, mainly to older population groups. Some countries are also recommending or
discussing the introduction of second booster doses in certain other vulnerable population groups, as well as healthcare
workers. Furthermore, EU/EEA countries are now discussing their future COVID-19 vaccination strategies and the need for
additional booster doses before the autumn/winter season when another wave and health service pressures related toother respiratory viruses may be expected.

Scope of this document
This document offers an overview of the available scientific and epidemiological evidence and provides public healthconsiderations to support decisions on the implementation of additional booster doses of COVID-19 vaccine. It aims toprovide some preliminary considerations and inputs to EU/EEA countries for evidence-based decision-making whenplanning vaccination campaigns, both at present and during the coming months, ahead of the next autumn/winter season.
This ECDC technical report builds upon and complements the previous one on public health considerations and evidence
to support decisions on the implementation of a second mRNA COVID-19 vaccine booster dose published on 28 April 2022[1]. The public health considerations presented in this document are based on the assessment of current epidemiologicaltrends and available scientific evidence. As such, they are preliminary and subject to change as more data become
available. The scope of these considerations is also focused on the second half of 2022, with an emphasis on the case forbooster vaccination and closing the primary vaccination gap in late summer/early autumn, and not for longer term COVID19 vaccination strategies. National Immunisation Technical Advisory Groups (NITAGs) will ultimately make national
decisions on the use of COVID-19 vaccines, taking into account the previous vaccination uptake and the epidemiologicalsituation in their countries.

Target audience
The target audiences for this document are the EU/EEA NITAGs, national public health institutes and ministries of healthin the EU/EEA, as well as public health experts and decision-makers at national and subnational level.

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ECDC TECHNICAL REPORT

Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

Epidemiological overview based on European
surveillance data
COVID-19 case notifications in the EU/EEA
In the post-acute phase of the SARS-CoV-2 pandemic, the introduction and emergence of new SARS-CoV-2 variants withincreased transmissibility and/or immune escape capacity, together with waning protection against infection and severe
disease from natural or vaccine-induced immunity, can result in new waves of virus transmission and surges of COVID-19
cases [2]. The emergence of Omicron – bearing the most significant profile of SARS-CoV-2 mutations evading existing
immunity to-date – in November 2021 resulted in a sharp increase in reported COVID-19 cases in the EU/EEA, reaching apeak in February 2021 (Figure 1, upper panel). The early surge in cases was largely attributable to Omicron sub-lineage
BA.1 [3]. The subsequent decline in reported cases observed between February and May 2022 was interrupted by a shortperiod of resurgence between March and April 2022, primarily driven by the replacement of Omicron sub-lineage BA.1
with the more transmissible sub-lineage BA.2, in combination with widespread relaxation of public health response
measures [1,4]. Following a sustained period of decline in April and May 2022, the EU/EEA 14-day COVID-19 casenotification rate has steadily increased in June 2022, with increases reported across all age groups (Figure 1, lower panel).
As of week 27, 2022 (week ending 10 July), the overall case notification rate in the EU/EEA was 1 109 cases per 100 000
population, corresponding to an 11% increase compared to the previous week.
Figure 1. EU/EEA 14-day COVID-19 case notification and death rates (upper panel) and age-specific 14-day
case notification rates (lower panel) (up to 10 July 2022)

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Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

BA.4 and BA.5 in the EU/EEA
On 13 June 2022, ECDC published an epidemiological update on the implications of the emergence and spread of SARSCoV-2 variants of concern BA.4 and BA.5 for the EU/EEA [5]. In this update, ECDC reported that whilst most EU/EEA
countries had detected low proportions of the SARS-CoV-2 variants BA.4 and BA.5, the estimated growth advantage of
BA.4 and BA.5 over other circulating strains would lead to these variants becoming dominant throughout the EU/EEA.
BA.4 or BA.5 are the dominant (>50%) circulating SARS-CoV-2 variants in 18 EU/EEA countries (Austria, Belgium, Cyprus,
Czechia, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Norway, Poland,
Portugal, Slovenia, Sweden) according to data submitted to GISAID or TESSy up to 03 July 2022 (Table 1) [6,7].
Table 1. EU/EEA SARS-CoV-2 variant proportions as reported to GISAD or TESSy

Note: BA.4/BA.5 means BA.4 or BA.5 cannot be distinguished from each other, as reported to TESSy by some countries using nonsequencing methods and/or a recoding of S-gene target failure (SGTF) reported to TESSy since week 20, 2022. Level 1a: Variant
proportion estimate with sufficient precision at a variant prevalence of 1% or lower. Level 1b: Variant proportion estimate with sufficientprecision at a variant prevalence of >1% to 2.5%. Level 1c: Variant proportion estimate with sufficient precision at a variant prevalenceof >2.5% to 5%. Level 2: Not able to estimate a variant proportion with sufficient precision at a variant prevalence of 5%.

COVID-19 severity indicators in the EU/EEA
In the context of recent changes to testing practices amongst younger age groups, ECDC currently considers case rates
among people aged 65+ years to be the most reliable indicator of changes in disease transmission, and ICU occupancy
and ICU admissions the most reliable indicators of severity in the current context. Importantly, lags and delays inreporting, as well as varying and low levels of reporting by different countries affect the quality of these indicators.
In Portugal, the emergence and subsequent dominance of BA.5 has occurred earlier than in other EU/EEA countries. Afteremerging in early April (week 13, 2022), BA.5 was the dominant (>50%) variant in circulation by mid-May (week 20,2022). This increase in BA.5 circulation was associated with a surge in COVID-19 incidence, observed across all age
groups, that peaked in early June at approximately 25% of the previous peak incidence recorded earlier in the Omicronwave in late January 2022. Whilst there is currently no indication of any significant change in severity for BA.4 or BA.55

ECDC TECHNICAL REPORT

Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

compared to previous Omicron sub-lineages [8], increased BA.5 circulation was associated with an observed increase in
hospitalisations and ICU admissions in Portugal, peaking in early June at a lower level than was observed in the previous
peak earlier in the Omicron wave. BA.5 associated increases in hospitalisations and ICU admissions have primarily been
driven by those aged 60 years and over [9]. The BA.4/BA.5 wave has peaked in Portugal, which has reported a sharply
decreasing trend in case rates among people aged 65 years and over for the last five weeks.
The emergence of BA.4 and BA.5 in other EU/EEA countries can be expected to result in increases in COVID-19 cases as
observed in Portugal in recent months. The extent of the increase will depend on various factors, including immune
protection against infection, the timing and coverage of COVID-19 vaccination and the extent, timing and variant
landscape of previous SARS-CoV-2 pandemic waves. In line with trends observed in Portugal, as of week 27, 2022 (weekending 10 July), case rates among people aged 65 years and older have increased in 23 of the 27 countries reportingthese data to TESSy, corresponding to a 23% increase at the EU/EEA level compared to the previous week, reaching
78.2% of the highest case rates during the pandemic (Table 2). Increasing transmission among older age groups isstarting to translate into severe disease. Of 34 countries with data on hospital or ICU admissions/occupancy, 12 (Austria,
Belgium, Cyprus, France, Greece, Ireland, Luxembourg, Malta, the Netherlands, Romania, Slovenia and Spain) reported anincreasing trend in at least one of these indicators compared with the previous week. Austria, Belgium, France, Greece,
Ireland, and Spain reported increases in both hospital and ICU indicators. Compared to maximum values observed during
the pandemic, current levels of ICU indicators are much lower (highest 20% in France) than hospital indicators (highest
57% in Greece) (Figure 2).
Table 2. Current trends in epidemiological indicators for EU/EEA; reporting week 27, 2022 (up to 10 July)
Indicator

Previous week

Reporting week

Number ofcountries withincreasing trend
924

Percentage of
pandemic maximum

2 260
1 109

Change compared
to previous week
(%)
11
15

Tests per 100 000 people
14-day case notification rate per
100 000
Test positivity (%)
14-day case rate per 100 000 (65+years)
Hospital admissions per 100 000
Hospital occupancy per 100 000
ICU admissions per 100 000
ICU occupancy per 100 000
14-day death rate per million

2 036
967
25.1
816

24.2
1 002

-3.5
23

12
23

20.9
78.2

8.8
12.6
0.6
0.8
8.5

9.4
14.6
0.7
0.9
8.3

6.3
16
17
12
-2.2

4
10
2
6
7

39
32.8
14.6
15.5
6.8

Figure 2. Summary of epidemiological indicators; reporting week 27, 2022 (up to 10 July)

6

22.1
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ECDC TECHNICAL REPORT

Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

Age-specific notification rate of hospitalised COVID-19 cases
Pooled analysis of case-based data reported to TESSy by eight EU/EEA countries with sufficient data completeness fromweek 48, 2021, to week 25, 2022, show that after the decrease observed in rates of severely ill cases in hospital(requiring admission to ICU and/or ventilation and/or extracorporeal membrane oxygenation) since Jan-Feb 2022, anincrease in trend is seen in recent weeks. This effect is more substantial among those aged 60 years and above (Figure 3a).
The same trend is observed looking at the notified cases requiring hospitalisation, based on pooled data from eight
countries (Figure 3b). The interpretation of this is made difficult by the considerable uncertainty concerning the proportionof cases hospitalised due to or with COVID-19. It is not normally possible to make this distinction in routine surveillancedata submitted to TESSy.
Since completeness of vaccination status reported to TESSy is limited for this pool of countries, we are unable to attributethe observed increases to individuals with a particular level of vaccination.
Figures 3a and 3b. Age-specific notification rate of cases admitted to ICU and/or requiring ventilation
and/or extracorporeal membrane oxygenation (3a) and age-specific notification rate of hospitalised cases(3b), week 48, 2021 to week 25, 2022

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ECDC TECHNICAL REPORT

Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

Risk of hospitalisation and death post-first COVID-19 boosterdose
For this analysis, cases were considered for all adult individuals aged 18 years and older with laboratory-confirmed
symptomatic SARS-CoV-2, as reported to TESSy by EU/EEA countries from 1 December 2021 to 29 May 2022 for
hospitalisation and from 1 December 2021 to 19 June 2022 for case fatality, with disease onset at least two weeks after
receiving their first booster dose. Individuals were then divided into groups who had received their first booster less thanor more than three months prior to the COVID-19 onset data. Unknown hospitalisation status and unknown deaths wererecoded as ‘No’. We believe that a very small proportion of unknown could be categorized as ‘Yes’, and misclassified
observations are very likely to be equally distributed among the groups under comparison. The proportion of
hospitalisation and deaths could therefore be slightly underestimated. The risk of hospitalisation and death was compared
between groups defined by sex, age (18−59, 60−79, 80+ years) and time from booster dose (less than or 3+ months),
adjusted by onset month.
Negative binomial models were run to calculate the Relative Risks (RR) and the 95% Confidence Interval (95% CI) of
hospitalisation and death.
Table 3. Main characteristics of COVID-19 cases who had a disease onset at least two weeks after receiving
their first COVID-19 vaccine booster dose, by hospitalisation status, 1 December 2021−29 May 2022
(N=398 414)
Total
Characteristic

Booster vaccination
Booster dose <3 months
Booster dose >=3 months
Sex
FemaleMale
Age at diagnosis (years)
18-59
60-79
80+
Onset month
December 2021
January 2022
February 2022
March 2022
April 2022
May 2022

Not hospitalised
Number of
Proportion ofcases
cases (%)
396 101
99.4

Hospitalised
Number of
Proportion ofcases
cases (%)
2 313
0.6

Number ofcases
398 414

Proportion ofcases (%)
100

288 648
109 76672.5
27.5

287 231
108 870

99.5
99.2

1 417
896

0.5
0.8

223 786
174 53456.2
43.8

222 748
173 259

99.5
99.3

1 038
1 275

0.5
0.7

238 870
132 900
26 644

60.0
33.4
6.7

238 471
131 648
25 982

99.8
99.1
97.5

399
1 252
662

0.2
0.9
2.5

8 257
107 960
137 739
115 771
23 714
4 973

2.1
27.1
34.6
29.1
5.9
1.2

8 064
107 425
137 004
115 084
23 589
4 935

97.7
99.5
99.5
99.4
99.5
99.2

193
535
735
687
125
38

2.3
0.5
0.5
0.6
0.5
0.8

Cases are from Estonia (735), France (4), Ireland (49), Luxembourg (46 863), Malta (2 996), Norway (877) Poland(346 873), Romania (17).
The main results for hospitalisation data are presented in Table 3. Of 398 414 individuals who acquired COVID-19
between 1 December 2021 and 29 May 2022 at least two weeks after receiving a first COVID-19 booster dose, 0.6%
required hospitalisation. This proportion was higher for the individuals who, at the time of onset, had received theirbooster dose more than three months before their diagnosis of COVID-19 (0.8%), compared to those who had received
their booster dose less than three months before (0.5%). The proportion was also higher for males (0.7%) than females(0.5%), and by age group, but remains quite stable in 2022, with the exception of an increase in May.

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Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

Table 4. Main characteristics of COVID-19 cases who had disease onset at least two weeks after receiving
their first COVID-19 vaccine booster dose, by case fatality, 1 December 2021−19 June 2022 (N= 321 664)
Total
Characteristic
Booster vaccination
Booster dose <3 months
Booster dose >=3 months
Sex
FemaleMale
Age at diagnosis (years)
18-59
60-79
80+
Onset month
December 2021
January 2022
February 2022
March 2022
April 2022
May 2022
June 2022

Survived
Number of
Proportion ofcases
cases (%)
321 327
99.90

Number ofcases
321 664

Proportion ofcases (%)
100

244 783
76 881

76.1
23.9

244 649
76 678179 529
142 06555.8
44.2

190 578
109 11221 9744 860
40 72697 151
134 727
30 929
8 179
5 092

Died
Number of
cases
337

Proportion ofcases (%)
0.10

99.95
99.74

134
203

0.05
0.26

179 368
141 889

99.9
99.88

161
176

0.09
0.12

59.3
33.9
6.8

190 571
109,023
21,733

100.0
99.92
98.90

7
89
241

0.00
0.08
1.10

1.5
12.7
30.2
41.9
9.6
2.5
1.6

4 836
40 65397 076
134 61430 886
8 171
5 091

99.51
99.82
99.92
99.92
99.86
99.90
99.98

24
73
75
113
43
8
1

0.49
0.18
0.08
0.08
0.14
0.10
0.02

Cases are from Estonia (735), France (4), Ireland (49), Luxembourg (46 863), Malta (2 996), the Netherlands (271 000), Romania (17).

The main results for case fatality data are presented in Table 4. Of 321 664 individuals who acquired COVID-19 between 1
December 2021 and 19 June 2022 at least two weeks after receiving a first COVID-19 booster dose, 0.10% died. This
proportion was higher for individuals who, at the time of onset, had received their booster dose more than three months
before (0.26%), compared to those who had received their booster dose less than three months before (0.05%). The
proportion was also higher for males (0.12%) than females (0.09%) and increased by age group while there was no clear
trend over time by month of onset in 2022.
Table 5. Adjusted relative risk of hospitalisation and death by time from booster vaccination, sex,
age group ***Adjusted relative risk of hospitalisation(95% CI) &Booster dose <3 months
Booster dose >=3 months
FemaleMale
18-59
60 to 79
80

Booster vaccination
Ref
1.17 (1.04-1.32) *Sex
Ref
1.49 (1.37-1.62) **Age at diagnosis (years)
Ref
5.32 (4.75-5.97) **13.71 (12.02-15.64) **Adjusted relative risk of death (95% CI) $Ref
4.81 (3.64-6.36) *Ref
1.39 (1.12-1.73) **Ref
20.80 (9.61-45.01) **204.31 (95.60-436.64) *** P-value<0.01 ** P-value<0.001 *** Further adjusted by onset month.
&
Cases are from Estonia (735), France (4), Ireland (49), Luxembourg (46 863), Malta (2 996), Norway (877) Poland (346 873), Romania(17).
$ Cases are from Estonia (735), France (4), Ireland (49), Luxembourg (46 863), Malta (2 996), the Netherlands (271 000), Romania (17).

The main results for the Relative Risks (RR) and the 95% Confidence Interval (95% CI) of hospitalisation and death are
shown in Table 5: the adjusted risk of hospitalisation increases by 17% for those having received a booster dose threemonths or more before diagnosis of COVID-19, compared to less than three months before. A significant increase in theadjusted risk of hospitalisation is seen also among men compared to women (RR=1.49, 95% CI: 1.37−1.62) and amongolder age groups. Regarding the adjusted risk of death, those who received the booster dose three months or more
before their diagnosis of COVID-19 have a 4.8-fold increase in the risk of dying after COVID-19 onset compared to those
who received it less than three months before. A significant increase in the adjusted risk of death is also seen for men(RR=1.39, 95% CI: 1.12−1.73) and older adults.

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Update of data on vaccine effectiveness andduration of protection following booster doses
against the Omicron variant
The recently published ECDC technical report on the second mRNA COVID-19 vaccine booster dose, published on 28 April
2022, included a review of the available scientific evidence on vaccine effectiveness against the Omicron variants BA.1 andBA.2 [1]. The updated overview of COVID-19 vaccine effectiveness (VE) in this section of the report is largely based on an
ongoing systematic review of COVID-19 vaccine effectiveness studies conducted by the International Vaccine AccessCenter, John Hopkins Bloomberg School of Public Health and the World Health Organization (WHO) [10], with the latest
update provided on 23 June 2022, and also through regular monitoring of published and preprint literature up to 4 July 2022.
Since the previous document, additional studies have been published that are included in the summaries below [11-19].

Vaccine effectiveness against infection over time with the
Omicron variant
Studies have found that VE against infection with the Delta and Omicron variant wanes over time, starting from around
two to three months after completing the primary series [1]. Similarly, the effectiveness against documented infection
wanes after administration of a first mRNA vaccine booster dose, from estimates within the range of 45−66% in the first 0
to three months, to around 25−45% between three to six months after the booster dose [20-26]. Estimates for
symptomatic infection (as compared to documented infection that also includes asymptomatic infection) are in a slightly
higher range, but direct comparisons between studies should be avoided due to different study designs, study population,
settings, etc [27-30]. The majority of these studies were conducted during the period where the Delta or Omicronsubvariants BA.1 and BA.2 were dominant.

Vaccine effectiveness against transmission with the Omicron
variant
Studies conducted in the UK investigating VE against transmission of Omicron and Delta variants in household and nonhousehold settings have found that transmission is less likely from cases receiving a booster dose compared to thosereceiving only primary vaccination [31,32], but that the protective effect is less pronounced for Omicron compared toDelta [31]. In summary, the studies suggest that booster doses in general have a modest effect and limited duration inpreventing Omicron transmission in the population [31-33].

Vaccine effectiveness against severe disease due to the Omicron
variant by time since first booster
Several studies conducted during the period when the Omicron subvariants BA.1 and BA.2 were dominant have estimatedvaccine effectiveness against severe disease or hospitalisation at sequential time points after the administration of a first
booster dose (third dose) [1]. In summary, these studies suggest that vaccine effectiveness against severe outcomes ishigh following the administration of a booster dose, with estimates of around 77−94% protection for up to two to threemonths after receiving it [12,16,19,28,29,34-38]. Studies with a follow-up period of three to six months after the first
booster dose are heterogenous, but generally show a gradual decrease in effectiveness against severe COVID-19
outcomes (VE estimates in the range of 53-100%) [34,35].
Few studies with a follow-up time longer than six months are available, but a nationwide cohort study from Slovenia
estimated the unadjusted vaccine effectiveness against severe acute respiratory infection (SARI) COVID-19 to be 96%(95% CI 90-99%) in 65-year-olds and above at six months or more after administration of a first booster dose [17]. The
corresponding effectiveness in younger age groups (18–49 and 50–64-year-olds) was estimated to be 100% at the same
follow-up time, but the number of cases were small in these groups and no confidence interval could be calculated. In
addition, a preprint study from Israel estimated the relative effectiveness of a first booster dose of Comirnaty to be 68%
for hospitalisation and death at six to seven months after the administration of the booster, but this was in comparison toprimary vaccination [11].
The available studies indicate that a first booster dose provides strong protection against severe disease in all theinvestigated age groups, and there are no clear signs of a more rapid waning in elderly groups. In a nationwide study
from Finland, the effectiveness against hospitalisation among 70 years old and above was estimated to be 90% (95% CI
87-93%) at 61 or more days after a first booster dose [12], and studies of age groups above 60 or 65 years old haveprovided estimates in the range 67-96% at three months or more after the first booster [11,15,16,29,37]. Nationwide
data from UK reported higher vaccine effectiveness against hospitalisations for 65 years and older (peak estimate of10

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92.4% and dropping to 76.9% at 15 or more weeks) compared to 18-64 year olds (82.4% and dropping to 53.6%) afteradministration of a first booster dose, but the observed discrepancy may be explained by younger age groups being more
likely to be hospitalised with COVID-19 as an incidental finding [25]. Similarly, a nationwide study from Denmark reported
slightly higher estimates in 60 years or older (94%, 95% CI 93-96%, dropping to 77%, 95% CI 71-82%, at 4+ months)
compared to 12-59 year olds (90%, 95% CI 88-91, dropping to 33%, 95% CI 1-55%) after administration of a booster
dose [15]. The nationwide cohort study from Slovenia also reports similar or higher VE for 65-year-olds and above
compared to younger age groups, although the number of cases are relatively few in the younger age groups [17].
These results are in agreement with summarised evidence on VE after primary vaccination suggesting that the waning ofprotection proceeds more rapidly in older age groups with regards to documented or symptomatic infection, but rates ofwaning appear to be more consistent, and not as rapid, across age groups for severe disease [39].

Vaccine efficacy and effectiveness of a second booster dose
against infection and severe disease
Data on the efficacy and effectiveness of a second mRNA vaccine booster (fourth dose) are still scarce at this point, with little
evidence on duration of protection due to short follow-up times of the available studies. In addition, most of the estimatesprovided so far are mainly calculated as a relative benefit compared to a third dose given three or four months earlier, rather
than against those who are unvaccinated. The Canadian study by Grewal et al shows that vaccine effectiveness against
infection and severe outcomes ≥7 days after administration of a second booster dose was higher by around 20-40
percentage points when using the unvaccinated as reference group instead of those given a first booster dose [16].
From the evidence available so far, a second booster seems to restore the humoral immune response to levels similar to
those shortly after the first booster dose as seen in an open-label non-randomised clinical study from Israel [40].
A second booster improves VE against infection, but this seems to wane rapidly as seen within the short follow-up period
available so far after the second booster dose. Studies on vaccine effectiveness against Omicron infection after the second
booster dose are heterogenous with regards to study design and follow-up time after the last dose, with estimates ranging
from 18 to 81%, comparing those that received a second booster dose with those that only received the first booster dose
[16,41-46]. A study from Israel that estimated the effectiveness at sequential time points reports a peak of 64% shortly
after receiving the second booster dose, declining to 30% at 10 weeks post second booster dose [43]. VE against severe
disease remains high (in the range of 62-77% depending on the specific outcome and study) during the short follow-up
period covered in the studies available so far, and seemingly restore the slightly reduced protection seen four months
after the first booster dose [16,41,43,44,46,47]. A recent preprint from Israel found that in addition to a maintained higheffectiveness of a first booster dose in preventing severe disease (during a seven month follow-up), a second booster
dose provides additional protection (assessed during Omicron BA.1 and BA.2 sublineage dominance) [11]. To summarise,
the benefit of a second booster dose against infection appears short-lived and limited. The protection of a first booster
dose against severe outcomes wanes gradually with time, and a second booster dose seemingly restores the protection
against severe disease, hospitalization and deaths.

Effect of vaccination and previous infection on Omicron sublineages
It is not fully understood to what extent the different sub-lineages of Omicron influence vaccine effectiveness. A casecontrol study from the southern part of Sweden reported on a rapid decline in vaccine effectiveness against severe
COVID-19 that coincided with the transition from Omicron BA.1 to BA.2 dominance in the region [48]. The decline wasobserved among persons who had received two vaccine doses only, while the effectiveness from the first booster (threedoses) remained stable. Other studies from Qatar and the UK have reported similar vaccine effectiveness estimates for the
sub-lineages BA.1 and BA.2 in relation to symptomatic infection [28,49], and hospitalisation or death [21].
At present, there are only limited data available on vaccine effectiveness against different clinical outcomes for Omicron
sub-lineages BA.4 and BA.5. There is preliminary analysis provided by the UK Health Security Agency that indicate that thevaccination status of cases infected with BA.4 and BA.5 is not significantly different to that of cases infected with BA.2
(adjusted odd ratio- aOR 1.13; 95% CI 0.88-1.44 and aOR 0.83; 95% CI 0.88-1.44, respectively). The authors observethat these early data do not indicate a difference in vaccine effectiveness against BA.4 or BA.5 as compared to BA.2 at thisstage, however a test-negative case control vaccine effectiveness study will be carried out when data are available [8]. A
study from South Africa that investigated clinical outcomes of Omicron BA.4/BA.5 infections reported that strong
protection against severe COVID-19 conferred by prior infection and vaccination was retained in the BA.4/BA.5 wave, withthree homologous doses of Janssen or Comirnaty or a heterologous combination of these providing 83% protection (95%
CI 60 to 93%) against severe COVID-19 hospitalisation or death [50]. In addition, a preliminary analysis from Portugal
comparing reinfections and vaccination breakthrough infections in BA.2 and BA.5 cases have suggested that BA.5 has
higher immune evasion from previous infections, and that the vaccine effectiveness against infection with BA.5 is reduced
compared to infection with BA.2 (preliminary information from unpublished study).
Some recent studies have investigated previous infection, vaccination and protective effect focusing on the Omicronsubvariant BA.4 and BA.5. A recent pre-print from Qatar found that the protection conferred by a previous infection
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against BA.4/BA.5 infection was modest when the previous infection involved a pre-Omicron variant, but strong when theprevious infection involved the Omicron BA.1 or BA.2 subvariant. Importantly, the protection from previous infection was
lower against BA.4/BA.5 than against BA.1/BA.2, consistent with BA.4/BA.5’s greater capacity for immune-system evasion.
Sensitivity analyses, adjusting for vaccination status in conditional logistic regression, showed similar results [51]. As
described above, the recent pre-print study from South Africa found that disease severity was similar amongst confirmed
COVID-19 cases in the BA.4/BA.5 and BA.1 periods in the context of growing immunity against SARS-CoV-2, due to priorinfection and vaccination, both of which were strongly protective. Prior confirmed infection was strongly protective against
severe hospitalisation or death (aHR 0.29; 95% CI 0.24; 0.36) as was vaccination with aHR (95% CI) of 0.17 (0.07;0.40); 0.37 (0.33; 0.42) and 0.26 (0.21; 0.32) for ‘first booster dose’, ‘two doses’ and ‘single dose’, respectively. Strong
protection against severe COVID-19 conferred by prior infection and vaccination was retained in the BA.4/BA.5 wave [50].

Evidence on the protective effect of hybrid immunity
Decision-making around the need for, and timing of additional vaccine doses requires careful consideration of the level of
immunity against SARS-CoV-2 in those populations targeted for vaccination. Population immunity can be broadly
estimated by measuring both vaccination coverage and the proportion of the population that has experienced priorinfection. Due to the recent exposure of large numbers of the population to the Omicron BA.1 and BA.2 variants, hybrid
immunity—developed via a combination of full primary course vaccination and at least one prior infection—is likely to play
an increasingly important role in protection at population level [52-54]. Hybrid immunity results in the improved inductionof site-specific, mucosal IgA (binds to virus/virus expressing host cells) and tissue-resident CD4 and CD8 T cells (lyseinfected host cells), which are not induced by injectable vaccines, and which may not be effectively induced by mild
natural infections [55]. In the context of Omicron, hybrid immunity has been shown to confer better protection against
both SARS-CoV-2 infection and severe outcomes (hospitalisation and death) when compared to vaccine-induced or
infection-induced immunity alone [18,19,21,24,53,54]. Evidence to-date also indicates that variant-specific protection
against infection and severe disease conferred by hybrid immune responses wane more slowly than protection conferredby vaccine-induced or infection-induced immunity alone [18,54].
As yet, no absolute serum antibody titre threshold has been established as a correlate of protection against SARS-CoV-2
infection, and immune correlates have not been established for protection against severe disease [56,57]. However,serum neutralising antibody titres are well-established predictors of protection against SARS-CoV-2 infection [57].
Nationally representative, age-stratified sero-epidemiological studies provide a basis for estimating the proportion of the
population with SARS-CoV-2-specific antibodies in a given country. These, in turn, provide a basis for estimating projecteddisease burden and evaluating the potential benefit of additional booster doses during periods of increased viralcirculation. Such studies are particularly informative when they use quantitative assays to determine the level of bothnatural and vaccine-induced antibodies in participating individuals to estimate the contribution of natural, vaccine-derived
and hybrid immunity in the population [58,59]. Given that serum antibodies wane over time [60], longitudinal or repeatedstudies with the same sampling strategy and common testing methodology are essential for understanding temporal
trends and risks, as is continued vigilance for the immune escape capabilities of newly emerging variants.
Population serosurveys estimating the proportion of the population experiencing prior infection before, during and after
the emergence of Omicron, show that despite observed increases in all age groups, older age groups appear less likely to
be exposed to or experience Omicron infections. In contrast to younger adults, persons 60 years of age or older face thehighest rates of hospitalisation and death, whilst having the lowest rates of combined infection and vaccination [58,61].
These age-specfic trends caution against the assumption that hybrid immunity is developed uniformly across the
population.
Evidence from studies looking at the combined effect of naturally-acquired immunity and vaccine-induced immunity clearlypoint to an extra layer of protection for those with hybrid immunity. However, the scale of natural-acquired immunity inpopulations is difficult to quantify due to issues such as the under-ascertainment of COVID-19 cases and reinfections, thelack of unbiased, longitudinal seroprevalence data, and the waning profiles of protection. In addition, few vaccine
effectiveness studies disaggregate results by prior infection status. For those that do, direct comparison between studies ischallenging, owing to heterogeneity (type of study, study population, type of vaccine, follow-up time, sequence of
infection/vaccination).

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Current recommendations on a second booster
dose in the EU/EEA
There are currently 20 EU/EEA countries recommending a second booster dose in immunocompetent individuals (Austria,
Croatia, Cyprus, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Luxembourg, Malta, theNetherlands, Norway, Poland, Portugal, Romania, Sweden). The second booster dose is under discussion in three
countries (Latvia, Lithuania, Spain). Twenty countries recommend a second booster for those in the 60+ to 80+ years
age group; 11 counties for long-term care facilities residents and four countries for healthcare workers or personnel
working in LTCFs. Other population groups are also included in some countries (home care; chronic diseases or underlying
conditions; Down syndrome; vaccinated with Jcovden – previously COVID-19 vaccine Janssen). The time interval after the
first booster dose differs among countries from an earliest time of three months up to five months (six months forhealthcare workers) (see Table A1 in Annex 2 for more details on country recommendations for booster doses).

Uptake of primary vaccination, first and second
booster doses in the EU/EEA
As of 10 July 2022, the uptake of the primary vaccination course against COVID-19 in the total EU/EEA population had
reached 72.8% (range: 29.8 – 86.4%) and is levelling off with very limited progression over the last month. The uptake ofthe first booster dose1 has reached 63.8% (range: 11.2 – 85.9%) among adults aged 18 years and above and isincreasing very slowly (average 0.1% weekly increase in the last month). The uptake of the first booster dose is still
showing some increase among younger adults aged 18−24 years (average 0.2% of weekly increase in the last month)(Figure 4). Among individuals above 60 years of age, the median uptake of the primary course and first booster dose hasreached 90.8% (range: 38.3-100%) and 83.1% (range: 13.5 – 97.5%) respectively (Figure 5). Overall, the progress invaccine uptake remains uneven across EU/EEA countries (Figure 6). [3].
Based on preliminary data reported to TESSy by 19 EU/EEA countries, ~16.5 million second booster doses2 have been
administered to adults 18+ years of age and 88% of them have been administered to those 60+ years of age. The
cumulative uptake of the second booster dose among reporting countries is 4.5% in 18+ years olds (range: <0.1-19.8%),
11.6% in those 60+ years old (range: <0.1-59.5%) and 20% in those 80+ years old (range: 0.1-80.1%) [62]. The uptake
among 60+ is still low in most countries (only four countries exceeded 25% of 60+ as of week 27: 59.5% in Sweden;
48.8% in the Netherlands; 40.9% in Ireland and 35% in Malta).
Table 6 summarises the uptake of the primary course, first and second booster dose by selected age group as of 10 July
2022. More information on COVID-19 vaccine doses administered and vaccine uptake rates can be found in the ECDC
Vaccine Tracker.

1

For surveillance purposes, this refers to the first additional dose of COVID-19 vaccine administered after the standard primary course.
Therefore, the count and uptake estimates may include both first booster doses administered to immunocompetent persons andadditional primary course doses administered to immunocompromised individuals.
2

For surveillance purposes, this refers to the second additional dose of COVID-19 vaccine administered after the standard primarycourse. Therefore, the count and uptake estimates may include both second booster doses administered to immunocompetent persons
and second additional doses administered to immunocompromised individuals after a standard primary course.

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Figure 4. Median cumulative uptake of first booster dose of COVID-19 vaccine by age group in the EU/EEA(as 10 July 2022)
100%
90%
83.3%
80%

81.4%
81.2%

70%

71.1%

60%
51.0%
50%
39.4%

40%
30%
20%
10%

4.1%
0.9%

0%

10-14 years

15-17 years

18-24 years

25-49 years

50-59 years

60-69 years

70-79 years

80+ years

Source: TESSy data reported by 30 countries.

Figure 5. Median cumulative uptake of one dose, primary course first and second booster of COVID-19
vaccine among 60+ in the EU/EEA (as of 10 July 2022)
100.0%
92.5%
90.0%

90.8%

80.0%

83.1%

70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
11.6%
10.0%
0.0%

One dosePrimary courseFirst booster

Second booster

Source: Cumulative uptake of the primary vaccination course based on the dosing schedule authorised in the EU/EEA. Numbers ofcountries reporting to TESSy: 30 for uptake primary course and first booster, 21 for second booster.

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Figure 6. Uptake of first booster dose of COVID-19 vaccine among adults aged 18 years and above in
EU/EEA countries (as of 10 July 2022)

Source: TESSy data reported by 30 countries.

Table 6. Summary table of COVID-19 vaccine uptake (as of 10 July 2022)
Population group

Uptake of primary course (range)

Uptake of the first booster dose Uptake of the second booster dose(range)(range)Total population

72.8% (29.8-86.4%)

52.9% (9.1-69.1%)

3.7% (<0.1-15.6%)

Adults (18+)

83.6% (35.6-94.5%)

63.8% (11.2-85.9%)

4.5% (<0.1-19.8%)

Persons aged 60+*

90.8% (38.3-100%)

83.1% (13.5-97.5%)

11.6% (<0.1-59.5%)

Persons aged 80+*

94.1% (26.2-100%)

83.3% (8.0-100%)20% (0.1-80.1%)

Note: cumulative uptake of the primary vaccination course based on the dosing schedule authorised in the EU/EEA. Numbers of countries
reporting: 30 for uptake primary course and first booster in total population and 18+, 21 for second booster; 30 for uptake primarycourse and first booster in 60+, 21 for second booster; 29 for uptake primary course and first booster in 80+ (missing Germany), 21 forsecond booster.
*Median uptake among reporting countries.

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Plans for autumn/winter vaccination campaigns
in EU/EEA countries
Several EU/EEA countries are currently discussing their future COVID-19 vaccination strategies and the need for additional
booster doses before the autumn/winter period when another wave may arrive. The planning of future vaccination
strategies and campaigns for the autumn is based on each country’s epidemiological situation, the effectiveness ofpreviously administered vaccinations, the potential availability of new, updated and more effective vaccines, and theidentification of risk groups. A few EU/EEA countries have already published recommendations for their autumn/wintervaccination campaigns:
•

•

•

•

•

The Belgian Superior Health Council has published recommendations that all risk groups should be vaccinated with anadditional booster by the end of September 2022 at the latest and that the campaign should be ‘as compact as
possible’ to maximise the benefits of vaccinating against COVID-19 (the interval should be at least three months, butpreferably six months for the administration of an additional booster dose). For the autumn/winter season 2022-2023
a proactive mass vaccination campaign will target adults 65 years of age and older, any patient with immune
suppression due to disease or treatment, any patient with at least one comorbidity, all pregnant women, all ‘persons
active in the care sector’ in and outside care institutions, and people living in the same household as people at highrisk of severe disease [63].
The Danish Health Authority has provided preliminary recommendations for an autumn vaccination campaign startingfrom 15 September for residents in LTCF and other vulnerable elderly people. From the 1 October, all individuals over
50 years of age and those who are severely immunocompromised (regardless of age) will be offered vaccination.
Final recommendations are expected in August [64].
The French Haute Autorité de Santé (HAS) has published recommendations to anticipate the organisation of a
vaccination booster campaign for autumn 2022 for the population groups most at risk of severe forms of the disease(immunocompromised, people 65+ years old and/or with comorbidities), with consideration of vaccination ofhealthcare professionals. The vaccination campaign against COVID-19 will be combined with the one for influenza. In
addition, as soon as updated vaccines obtain their marketing authorisation, HAS will assess them, specify their
inclusion in the vaccine strategy and indicate, where applicable, the preferred type of vaccine to be used for each
population according to their characteristics [36].
The Portuguese Directorate-General of Health published interin recommendations for the next autumn-winter 20222023 COVID-19 vaccination strategy. It is planned that, at the beginning of September, a new dose/booster of
COVID-19 vaccine will be given to: nursing home residents; people aged 65 and over; people aged 18 years and overwith comorbidities that have a risk for COVID-19; healthcare and nursing home professionals. The inclusion of otherpriority groups is under discussion. Portugal plans to use the best available vaccine for the variants in circulation(country communication).
The Swedish Public Health Agency has provided new recommendations for the autumn COVID-19 vaccination
campaign starting from 1 September 2022, to adults 65 years of age and older and people in risk groups from theage of 18 years (including among others pregnant women, people with weakened immune systems, people with heart
and lung disease). For adults 18-64 years of age, the recommendation remains for one booster dose, however
anyone can take a second booster in this age group if they request it [65].

Updated COVID-19 vaccines
The mRNA technology is the only platform that can deliver updated versions of approved vaccines in time for vaccination
campaigns for this autumn/winter. Currently under investigation are monovalent Omicron BA.1 vaccines and bivalent
Omicron BA.1 and original strain vaccines from both Pfizer/BioNTech and Moderna. Following a recent FDA statement,
vaccines incorporating BA4/5 are expected to be developed as well [66].
On 15 June 2022, EMA started a rolling review of an Omicron-adapted Comirnaty COVID-19 vaccine [67]. The review will
initially focus on chemistry, manufacturing and controls (CMC), which relate to the manufacturing of the vaccine. As thecompany makes progress in the development of its adapted vaccine, EMA will receive more data, including data on the
immune response to the vaccine as well as data on neutralisation of Omicron subvariants, including BA4/5. On 17 June
2022, EMA started a rolling review for a bivalent Spikevax COVID-19 vaccine adapted to provide better protection against
two strains of SARS-CoV-2, the original strain and the BA.1 Omicron variant of concern [68].
On 17 June 2022, the WHO Technical Advisory Group on COVID-19 Vaccination Composition (TAG-CO-VAC) issued aninterim statement on the composition of current COVID-19 vaccines and concluded that, given the uncertainties of further
evolution, it may be prudent to pursue the additional objective of COVID-19 vaccination of achieving a greater breadth in
the immune response against circulating and emerging variants, while retaining protection against severe disease anddeath. Available data indicate that the inclusion of Omicron in an updated vaccine composition may be beneficial if
administered as a booster dose to those who have already received a COVID-19 vaccination primary series [69].

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An International Coalition of Medicines Regularity Authorities (ICMRA) workshop took place on 30 June to discuss withinternational regulators whether vaccines need to be updated and how. ICMRA members and WHO agreed that authorised
COVID-19 vaccines continue to offer protection against severe disease, hospitalisation and death and encouraged theiruse, where available, both as primary series and as booster doses. Global regulators however also acknowledged that thecontinuous evolution of SARS-CoV-2 reduces the protection offered by the approved vaccines against infection and mild
disease. Although the Omicron BA.4 and BA.5 subvariants seem to be taking over in many parts of the world, experiencehas shown that new variants may emerge rapidly and replace the currently circulating ones after short-lived waves.
Preliminary data indicate that adapted mRNA vaccines, which incorporate an Omicron variant strain, can increase andextend protection, when used as a booster. Additionally, according to emerging data, a bivalent mRNA vaccine targetingtwo strains of SARS-CoV-2, one of which should be an Omicron strain, may provide some advantages in widening theimmune response. Bivalent vaccines could be considered initially for use as boosters. Their use for primary vaccination
might be supported in the future when further data become available [70].
Additionally, there are new candidate vaccines that contain the Beta variant strain that are currently under assessment by
the EMA and they might represent an additional modality for booster doses, if an approval is confirmed before autumn.

Estimating the impact of future COVID-19
vaccination campaigns on the hospitalisation
risk in individuals aged older than 60 years bymathematical modelling
Modelling approach and parameters to estimate the vaccine effectivenessagainst infection and hospitalisation at population levelWe estimate vaccine induced protection against infection and against severe disease based on available data of vaccine
effectiveness (VE) measured against Omicron subvariant BA.1. We assume that VE against infection wanes following afunctional shape based on decaying antibody titers [71]. We use this relationship to back-calculate VE at full vaccine effect(two weeks post administration), which we denote as VE0. For Corminaty we estimate VE0=0.76 [27,34,72], for Spikevax
we estimate VE0=0.87 [72], for Vaxzevria we estimate VE0=0.46 [72], and due to lack of data we assume the same VE0
for COVID-19 Vaccine Janssen as for Vaxzevria.
Given the large uncertainty around the waning of immune protection from vaccines, we assume an optimistic andpessimistic waning scenario of the VE against infection. In the optimistic scenario, the relative VE against infection
decreases by 60% after 35 weeks, and in the pessimistic scenario the relative VE against infection decreases by 60% after
only 13 weeks. Assuming the functional waning shape based on antibody titers [71], immunity keeps declining beyond
those time points. For VE against hospitalisation we assume the same protection from all vaccine types, which weestimate as VE0=0.92 [73,74]. Across scenarios we assume that VE against severe outcome wanes four times slower
compared to VE against infection. This captures waning of the relative VE against severe outcome by 7% to 24% after six
months (for the optimistic and pessimistic scenario, respectively).
We assume that the VE after a first or second booster is independent of the vaccine products used in the primary
vaccination series, and we do not differentiate between a Comirnaty or Spikevax booster. We assume the protection of afirst booster against infection to be VE0=0.86 [35,73,75], and against hospitalisation to be VE0=0.94 [76]. We assume
that the vaccine-induced protection following the booster decays the same way as following the primary vaccination
schedule, both for the vaccine-induced protection against infection and against severe outcomes. We assume that asecond booster dose restores the vaccine-induced protection against infection and severe disease of the first booster, andhas the same waning profile.
Due to lack of data, we assume no increased transmissibility of BA.4 and BA.5 in comparison to previous Omicronsubvariants. Hence, we consider that the growth advantage of BA.4 and BA.5 is due to an increase of immune escape of
vaccine-induced and naturally-acquired protection. In Figures 8 and 9 below, we vary the immune escape of vaccineinduced protection against infection due to BA.4 and BA.5 in comparison to previous Omicron subvariants from 0-20%.
This range is in agreement with preliminary data that was shared with us confidentially. As there is currently no otherindication, we assume the same severity for BA.4 or BA.5 as compared to previous Omicron lineages.

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Model predictions of the future BA.4 and BA.5 proportions and the vaccineinduced protection against infection in the EU/EEA
Sequencing data from GISAID of COVID-19 cases until early June 2022 indicate that the Omicron subvariants BA.4 andBA.5 are quickly taking over in countries throughout the EU/EEA [7]. We predict the future combined BA.4 and BA.5
proportion for every country in the EU/EEA for which sufficiently reliable and recent sequencing data is available in GISAID(at least 100 Omicron sequences on 16 May or later, altogether 16 countries). For each of these EU/EEA countries, we fit
a logistic curve to the past sequencing data, which matches the observed data well and yields predictions of the future
proportion of BA.4 and BA.5. As shown in Figure 7, by end-July 2022 the vast majority of all COVID-19 cases (>95%) in
the EU/EEA are predicted to be due to BA.4 or BA.5. We emphasise that the predicted proportion of BA.4/BA.5 infectionsin Figure 7 is obtained directly from fitting to observations of sequencing data, which does not require the transmissibility
or immune-evasion of BA.4 and BA.5.
We note that, as with any extrapolation, there are major uncertainties that may affect the accuracy of our predictions inFigure 7. First, only a subset of EU/EEA countries provided sufficiently reliable and recent sequencing data (16 of 30
countries). Hence, the predictions in Figure 7 are applicable to the whole EU/EEA only under the assumption that a similar
trend holds also for countries for which sufficiently reliable or recent sequencing data was not available. Indeed, theestimated proportion of BA.4 and BA.5 for countries with sufficient sequencing data varied less than 1.8% from the mean
prediction at the end of July 2022. Second, also for the subset of countries with available sequencing data, the predictions
are subject to uncertainties due to country-specific testing and sequencing practices, which have been changing overtime, as well as the viral characteristics of the Omicron subvariants BA.4 and BA.5, including changes in the rates ofasymptomatic cases and PCR test sensitivities.
Figure 7. Predicted proportion of SARS-CoV-2 infections in the EU/EEA caused by the Omicron subvariants
BA.4 or BA.5

Note: The predictions for each considered EU/EEA country fall within the grey shaded area, and the solid black line is the mean acrossthe predictions of the considered EU/EEA countries.

Preliminary data suggest that BA.4 and BA.5 may result in a substantial reduction of the population-level vaccine
protection against infection (the vaccine effectiveness against infection, averaged over the whole population including
non-vaccinated individuals) and an increased probability of reinfections. Additionally, the population-level vaccine
protection against infection from the primary vaccination course and the first booster dose is likely to have waned
substantially by July 2022. We emphasise that, in contrast to the potential reduction of the vaccine effectiveness against
infection due to BA.4 or BA.5, there is currently no indication of a decrease in vaccine effectiveness against severe
outcome due to BA.4 or BA.5 in comparison to previous Omicron lineages; hence, we assume the same vaccine-induced
protection against severe outcomes for BA.4 and BA.5 as for earlier Omicron lineages.

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Figure 8 presents estimates of the reduction of vaccine protection against infection at the population-level; we build upon
the predictions of the BA.4 and BA.5 proportion shown in Figure 7 and assume that the vaccine effectiveness against
infection is reduced by 0%-20% due to BA.4 and BA.5, as compared to previous Omicron sublineages (due to the current
lack of evidence, we assume that both BA.4 and BA.5 result in the same reduction of the vaccine effectiveness).
Figure 8. Predicted vaccine effectiveness against infection (averaged across the whole EU/EEA population,and based on assumptions of increasing proportion of BA.4/5 infections from April onwards)

Note: The predictions for each EU/EEA country and for each uncertain spreading parameter fall within the grey shaded area, and the solid
black line is the mean across the predictions of the considered EU/EEA countries and parameter uncertainties. Note that the vaccineinduced protection against infection at a population-level does not include protection against infection from prior infections which would
increase the population level protection against infection.

Figure 8 shows that, after a peak due to the first booster rollout in early 2022, the vaccine-induced protection against
infection at population-level, taking into account the estimated increasing proportion of BA.4 and BA.5 infections during
the summer, has been decreasing steadily. By September 2022, the estimated vaccine effectiveness against infection,
averaged across the whole population of the respective countries, is reduced to 3%-20% in the EU/EEA. The broad rangeof the predictions reflect substantial uncertainties regarding crucial parameters, including the waning of the vaccine
effectiveness against infection, the current and future proportion of BA.4 and BA.5 and the reduction of the vaccine
effectiveness against infection due to BA.4 and BA.5. The estimated substantial waning of the vaccine effectivenessagainst infection is consistent with the recent rise of COVID-19 notifications rates in the EU/EEA in the past three weeks.
Further circulation of SARS-CoV-2 across the EU/EEA is probable in autumn and winter 2022, which results in continued
exposure for at-risk groups. We emphasise that Figure 8 considers the vaccine effectiveness against infection, the vaccine
effectiveness against severe disease is considered further below.

Scenarios for vaccination campaigns in summer and autumn
To assess the risk of a continued exposure of risk groups to SARS-CoV-2 infection, we conduct scenario analyses until theend of December 2022, for which we explore different vaccination strategies for countries that have not started a rolloutof the second booster. In the following, we consider scenarios of rolling out a second booster to elderly individuals andclosing the gaps in vaccination by increasing coverage of the primary course and/or first booster dose, as given in detailbelow:

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•

•

•

Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

Second booster dose rollout. In this scenario, we consider a rollout of a second booster to individuals older than
60 years who already received a first booster dose. We consider an eventual uptake of 75% of the second booster
dose among individuals older than 60 who received a first booster. We consider that the rollout starts on 18 July
2022, and we assume the same speed of the second booster rollout as observed for the past first booster rollout. In
Annex 1, we also evaluate the impact of a different start date of the second booster rollout (1 August 2022, 1
September 2022, or 1 October 2022) and the impact of a faster booster rollout, where the eventual uptake of 75% isattained in six weeks. Our modelling focuses explicitly on vaccine effectiveness and second boosters given to
individuals of a certain age category (older than 60 years) since vaccine coverage or other data is available by age group.
Closing the coverage gaps of the first booster and primary vaccination series. We consider an optimistic
scenario of reducing the vaccination coverage gap for the first booster dose by 50% for individuals between 18 and59 years and by 75% for individuals older than 60 years by 1 October 2022. Additionally, we consider that thecoverage gap for the primary vaccination series for individuals older than 18 years is reduced by 50% by 1 October 2022.
Baseline scenario. In this scenario, we consider that there are no new vaccine campaigns, while current vaccination
uptake trends continue.

To capture the uncertainty concerning future viral circulation, we assess each of these intervention scenarios for a rangeof parameter settings relating to the waning of protection against infection and severe disease, as well as uncertainties
relating to the spread of BA.4 and BA.5 and the resulting reduction in vaccine effectiveness against transmission. The
results are presented as ranges of estimates across these different settings.

Model predictions of the future hospitalisation risk andconclusions
Figure 9 shows the estimated vaccine effectiveness against hospitalisation over time, averaged over all individuals above
60 years, for the three different vaccination scenarios. The results show that a second booster rollout has a substantial
effect on the protection of individuals older than 60 years against hospitalisation, which is particularly large for countries
with a high uptake of the first booster dose. More specifically, the expected median absolute increase (in percentage
points) of the vaccine-induced protection against hospitalisation on 1 November 2022 due to a second booster rollout
starting on 18 July 2022 is 17% (95% UI 6-34%) for countries with a high first booster uptake (see Figure 9A), and 5%(95% UI 1-24%) for countries with a low first booster uptake (see Figure 9C). Furthermore, countries with a low first
booster uptake would benefit strongly from a vaccination campaign that aims to reduce the vaccination gap of the primary
vaccination series and the first booster (see Figure 9D). The expected median absolute increase (in percentage points) of
the vaccine-induced protection against hospitalisation on 1 November 2022 due to closing the vaccination coverage gaps
for countries with a low first booster uptake is 16% (95% UI 10-41%) for countries with a low first booster uptake (seeFigure 9D).
Figure 9. Predicted vaccine effectiveness against hospitalisation, averaged across all individuals older than
60 years.

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Note: the left two subplots compare the baseline scenario with the second booster scenario (starting on 18 July 2022), and the right two
subplots compare the baseline scenario with the scenario of closing the vaccination coverage gaps. The top and bottom rows correspondto countries with a high and low first booster uptake (of more or fewer than 40% of the total population, respectively, on 1 July 2022).
The predictions for each EU/EEA country and for each uncertain spreading parameter fall within the respective shaded area, and the solidline is the respective mean across the predictions of the considered EU/EEA countries and parameter uncertainties. The expected medianabsolute increase (in percentage points) of the vaccine-induced protection against hospitalisation on 1 November 2022 due to a second
booster rollout starting on 18 July 2022 is 17% (95% UI 6-34%) for countries with a high first booster uptake (see Figure 9A), and 5%(95% UI 1-24%) for countries with a low first booster uptake (see Figure 9C). The expected median absolute increase (in percentage
points) of the vaccine-induced protection against hospitalisation on 1 November 2022 due to closing the vaccination coverage gaps is 3%(95% UI 0-10%) for countries with a high first booster uptake (see Figure 9B), and 16% (95% UI 10-41%) for countries with a low first
booster uptake (see Figure 9D).

In countries who began second booster vaccination before 18 July 2022, at a similar rollout speed as for the first booster
dose, the vaccine-derived protection is expected to be induced earlier than shown in Figure 9, with the curve shifting to
the left. In settings with a slow uptake speed before 18 July 2022, the results are not expected to materially change.
Furthermore, we evaluate the impact of different timings of the second booster rollout on the future hospitalisation risk.
Figure A1 in Annex 1 shows that there is a considerable advantage of an earlier second booster rollout (18 July) as
compared to a later rollout (starting on 1 August 2022, 1 September 2022 and 1 October 2022, respectively). Morespecifically, Figure A1 shows that the predicted averaged vaccine effectiveness against hospitalisation of the earlier second
booster rollout is larger for almost the entire period from 18 July 2022 until 31 December 2022, although the uncertainty
intervals are overlapping.
The speed of the second booster rollout in Figure 9 is based on the speed of country-specific first booster rollouts
observed historically. The uncertainty bands shown in that figure thus contain both slower and faster rollouts. However, toreflect on the potential advantages of achieving an even faster uptake in second booster vaccines, Figure A2 in Annex 1
shows the effect of an accelerated second booster rollout, which we assumed to reach the eventual uptake plateau of
75% within six weeks. While noting the large uncertainties, a faster second booster rollout starting on 1 September 2022
results in a comparable vaccine effectiveness against hospitalisation by November as the second booster rollout shown in
Figure 9 (starting 18 July 2022). However, given the rise in case numbers due to BA.4 and BA.5 at the moment, and if
expectations are that a 75% uptake may not be reached within six weeks, then it would be prudent to start the rollout
now. Furthermore, a faster second booster rollout starting on 1 October 2022 results in lower vaccine effectivenessagainst hospitalisation during September/October relative to the second booster rollout shown in Figure 9 (see Figure A2,
Annex 1).
We emphasise that Figures 8, 9, A1 and A2 focus on the decrease of vaccine-induced protection against infection andhospitalisation, respectively, due to waning over time and the potential increase of immune-escape of BA.4 and BA.5,
while we are not considering additional immunity from previous infections in the population. Naturally-acquired protection
does have a considerable impact on the protection against infection and hospitalisation, but the precise extent of
naturally-acquired protection in the population is unclear due to substantial uncertainties, which include the underascertainment of COVID-19 cases and reinfections, the lack of unbiased and recent seroprevalence data, and the waning
profiles of natural, vaccine-induced and hybrid protection. The substantial change in vaccine-induced protection in Figures
8, 9, A1 and A2 suggests a considerable reduction of the protection of individuals above 60 years who have not recently
been infected by SARS-CoV-2. Due to fewer human-to-human contacts in general, higher uptakes of the primary
vaccination series and first booster doses, and more cautious behaviour, the likelihood of having acquired past infection asa result of exposure in recent months may be particularly low amongst this group.
We summarise the conclusions from ECDC’s mathematical modelling as:
•

•

•

•

There is a substantial, steady decrease of the vaccine-induced protection against infection at population-level due towaning, and this trend might be exacerbated due to BA.4 and BA.5 Omicron subvariants (based on preliminary
evidence). In contrast, there is currently no indication that BA.4 or BA.5 lead to a decrease in vaccine-induced
protection against severe outcomes in comparison to previous Omicron lineages.
For countries with an uptake of >40% of the first booster among the whole population, a second booster rollout canhave a substantial impact on restoring protection against hospitalisation in individuals older than 60 years in autumn
2022. The expected median absolute increase (in percentage points) of the vaccine-induced protection against
hospitalisation in individuals older than 60 years due to a second booster rollout starting on 18 July 2022 is 17%(95% UI 6-34%) on 1 November 2022.
For countries with an uptake of <40% of the first booster among the whole population, closing vaccination coverage
gaps of the primary vaccination series and the first booster has a larger effect than a second booster rollout, with an
expected median absolute increase (in percentage points) of the vaccine-induced protection in individuals older than
60 years of 16% (95% UI 10-41%) and 5% (95% UI 1-24%) on 1 November 2022, respectively.
An earlier second booster rollout (mid-July 2022) results in a larger protection against hospitalisation in the
population above 60 years for the rest of 2022 compared to a later second booster rollout. The benefit in terms ofvaccine-induced protection against hospitalisation in the population 60+ decreases the more the starting date of thesecond booster rollout is moved to a later starting date (we evaluate a starting date in July, August, September or
October).

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The predictions from mathematical modelling are subject to substantial uncertainties for assessing different vaccination
campaigns, including the effectiveness of vaccines against BA.4 and BA.5, the prevalence and severity of BA.4 and BA.5,
the associated effectiveness of the vaccine including the speed of waning, the effect of BA.4 and BA.5 on the probabilityof reinfections, the emergence of new SARS-CoV-2 variants, and the effect of hybrid immunity. Naturally-acquired
protection from previous SARS-CoV-2 infections significantly complements the vaccine-induced protection against infection
and hospitalisation in Figures 8 and 9, respectively. The level of naturally-acquired protection is uncertain due to lack of
epidemiological evidence and data, including under-ascertainment of SARS-CoV-2 infections, lack of recent and unbiased
seroprevalence data in the EU/EEA, waning profiles of naturally- and vaccine-induced protection, and the cross-protection
and immune escape of different SARS-CoV-2 variants.

Public health considerations for vaccination
strategies and campaigns
Considerations on additional booster doses, target groups andtimingBased on current projections, SARS-CoV-2 Omicron variants BA.4 and BA.5 are expected to become dominant across
EU/EEA countries and by the end of July 2022 most COVID-19 cases (>95%) in the EU/EEA will be due to BA.4 or BA.5.
As of 10 July 2022, the overall notification rates of COVID-19 cases in the EU/EEA remain high and have been increasing
for the past five weeks, and case rates among people aged 65 years and over increased in 23 of the 27 reporting
countries. These increases are still relatively recent, and they signal the start of a widespread wave driven by the BA.4
and BA.5 variants of concern, although with a growth rate likely slower than observed during the earlier emergence of
BA.1 and BA.2. The increasing transmission among older age groups is starting to translate into severe disease, andtwelve countries reported an increasing trend in at least one indicator of either hospital or ICU admissions/occupancy
compared with the previous week. At the same time, even though the EU/EEA death rate has remained stable for the last
five weeks, the forecast for the period up to 31 July indicates that both case notification rates and death rates will
increase [77].
Current evidence shows that protection against infection due to Omicron variant (BA.1 and BA.2) starts waning two to
three months after completing the primary series, is largely lost after six months and also wanes rapidly after the first
booster dose. Protection is stronger and more durable against severe disease, although the balance of the evidence
indicates gradual waning three to six months after the first booster dose. A second mRNA booster dose seemingly restores
VE against severe disease, which remains stable for up to 10 weeks. Vaccine effectiveness data against BA.4 and BA.5
associated outcomes are still very limited, but thus far there is no evidence of reduced vaccine effectiveness against
severe outcomes from BA.4 or BA.5 in comparison to previous Omicron lineages. However, as in previous waves, anoverall increase in COVID-19 cases can result in a rise in hospitalisations, ICU admissions and deaths. Some signals in thisdirection are starting to emerge in a few countries with earlier progression towards dominance of BA.4 and BA.5 andcorresponding waves with increased rates of infection.
In April 2022, ECDC assessed that in anticipation of future waves, it was expected that the administration of a second
booster dose of mRNA vaccine would avert a significant number of hospitalisations and deaths and be needed for thosegroups most at risk of severe disease, such as adults 60 years and older and individuals with underlying comorbidities, withclearest public health benefit for those aged 80 years and above [1]. Such additional doses would be of greatest value if
administered closer to expected periods of increased viral circulation, but before virus circulation reaches high levels. The
age of 60 years as a cut-off for the recommendation was based on the higher observed age-specific notification rates of
hospitalisation and ICU admission, increased adjusted risk of hospitalisation and death post first booster dose, and projected
reduction in cumulative predicted deaths and SARS-CoV-2 cases by a second booster rollout in this population group.
Based on the new mathematical modelling presented in this document, for countries with an uptake of >40% of the first
booster among the whole population, a second booster rollout among 60+ can have a substantial impact on restoring
vaccine-induced protection against hospitalisation in this population from mid-July to the end of 2022 and an earlier second
booster rollout among 60+ in mid-July 2022 results in a larger vaccine-induced protection against hospitalisation for the
rest of 2022 compared to a later second booster rollout. There are currently twenty EU/EEA countries with recommendations
on the use of a second booster in age group varying from 60+ to 80+ years, but as of 10 July 2022, the uptake of thesecond booster is still low in the EU/EEA (20% among 80+; 11.6% among 60+) and uneven across countries.

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General considerations
Considering that with currently available vaccines, protection against infections rapidly wanes and effectiveness ontransmission is modest, at this stage of the pandemic the objective of COVID-19 vaccination campaigns continues to be to
reduce COVID-19 hospitalisation, severe disease and death, and to protect health systems.
Improving COVID-19 vaccine uptake of the primary course and first booster dose in eligible individuals who are yet toreceive them remains a priority, especially for population groups at higher risk of severe outcomes and for countries withlower uptake of primary course and first booster dose.

Considerations for vaccination strategies in the summer
In light of the projection of a widespread wave driven by BA.4 and BA.5, waning protection against infection, and thecurrent signal of increased rates of infection and severe disease in several countries, an early second mRNA vaccine
booster rollout, not only among 80+ but also for adults between the ages of 60 and 79 years and individuals with
underlying comorbidities regardless of age (including moderately to severely immunocompromised individuals), should
now be considered to prevent severe disease and safeguard health system capacity, and countries should consider a rapid
deployment. This would be particularly relevant and impactful in countries where the BA.4/BA.5 wave is starting or has
not yet peaked. Second booster doses could be administered at least four months after the previous one, with a focus on
people who received a previous booster more than six months ago. Continued close epidemiological and vaccine
effectiveness monitoring continues to be essential to rapidly detect signals of waning protection and tailor the deploymentof additional booster doses among population groups most at risk based on local data.
At the moment, for immunocompetent individuals below 60 years of age, unless they have underlying comorbidities, there
is no clear epidemiological evidence to support the administration of a second booster dose, even though a certain degreeof waning protection against severe outcomes may be expected overtime. The extension of the indication for additional
booster doses to younger age groups will need to be reassessed based on epidemiological trends, emerging vaccine
effectiveness evidence, performance and availability of future updated vaccines.
Considering the low and rapidly waning protection against infection and modest effect on transmission obtained with
COVID-19 vaccines currently available, the early administration of a second booster dose to HCW and personnel working
in LTCF for infection control purpose is likely to offer only modest benefits in terms of limiting the risks of transmission tovulnerable people in their care and be of limited duration. HCW and LTCF personnel may receive a second booster dose
for their own protection if they belong to any prioritised population group based on age or due to underlying
comorbidities. It should be ensured that LTCF residents receive the recommended booster doses, as they are effective in
reducing morbidity and mortality in this group. In addition, NPIs in healthcare settings including LTCFs and other healthcare settings, such as use of face masks, remain effective measures to protect the vulnerable populations in thesesettings. Finally, access to therapeutics is an additional key measure for the protection of LTCF residents from severe
outcomes. LTCFs should ensure the early detection and containment of outbreaks, as larger outbreaks are linked to lower
protection by vaccines against infection presumably due to repeated exposure SARS-CoV-2 [78].

Considerations for vaccination strategies in the autumn/winterFurther waves of infection may be expected, including in the autumn/winter season of this year. The key drivers forfurther waves will be a combination of waning protection from vaccines and natural immunity, further evolution andemergence of variants, and, during autumn/winter months, increased indoor activity, among other factors. In anticipationof this, countries should consider the need for the rollout of further additional booster doses to be administered topopulation groups at risk of severe disease (e.g. 60+,individuals with underlying comorbidities, immunocompromised
individuals and pregnant women), including later in this year. If further boosters are to be offered in the autumn/winter,countries should consider the need for combined campaigns for vaccination against COVID-19 and influenza, since such a
combined approach provides efficiencies in administration logistics and costs. The boosting of HCW and LTCF personnel
should also be considered for this later rollout. If adapted vaccines will show increased neutralisation against Omicron
variants, indicating a possible higher effect against infection and transmission, they may be used to provide both direct
and indirect protection. The need for, and the optimal timing of, further additional booster doses in autumn/winter mayvary across countries, especially depending on the timing of the rollout of second boosters in spring/summer 2022 andemerging evidence of continued protection against severe disease in those that have received a second booster dose.
In addition, updated Omicron-adapted vaccines will likely be authorised for use in the EU in September and possibly
available some time during the last trimester of 2022, however, the exact distribution timeline and available supplies of
new vaccines are currently being defined with manufacturers. Efficacy data are currently under evaluation by EMA [67].
Future vaccination strategies may therefore also differ depending on the availability of these updated vaccines and theircharacteristics, and countries may have to use a mix of current and new vaccines depending on the timing of theiravailability and distribution. Nevertheless, it is important to continue the efforts to increase vaccination rates with available
vaccines for groups at high risk for severe disease in a timely manner, and not to wait for the new Omicron-adapted
vaccines. Depending on available supplies, different types of vaccines may therefore be used for different strategies andpopulation groups depending on the characteristics of the updated vaccines compared to first-generation ones and thepotential emergence of further new variants.

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Furthermore, the frequency of re-vaccination needs to be carefully considered to allow that enough time has elapsed sinceprevious vaccination. Data on the safety of a fourth dose of mRNA COVID-19 vaccine are limited, but so far the adverse
events are mostly similar to those following previous doses and are short-lived [40,79]. Data emerging from the use of thesecond booster will continue to be assessed to determine if repeated boosters show any difference with respect to theoverall safety profile.
These public health considerations are based on available scientific evidence and current epidemiological trends, and will
be periodically reassessed. Considering that COVID-19 vaccination strategies and uptake, extent and timing of pandemic
waves, circulation and timing of dominance of variants, among other factors, may differ across EU/EEA countries, NITAGs
will ultimately make national decisions on the use of COVID-19 vaccines, taking into account previous vaccination uptake
and epidemiological situation in their countries.
The scope of these considerations is focused on the second half of 2022, with an emphasis on the case for booster
vaccination and closing the primary vaccination gap in late summer/early autumn, and not for longer term COVID-19
vaccination strategies. The administration of additional booster doses, both in the second half of 2022 as well as for the
longer term COVID-19 vaccination strategy, may have a significant impact on the capacity of health systems to deliver
COVID-19 vaccinations in the context of other competing public health priorities in the post-pandemic phase and alreadyoverburdened health services. At population level, vaccination fatigue could also undermine efforts to deliver vaccines togroups at higher risk of severe disease. Long-term vaccination strategies, including frequency of boosters, type of
vaccines and target population groups, will need to balance scientific evidence and epidemiological trends with healthsystem and economic implications, including investments in capacity to respond to future health service pressure of
COVID-19, influenza and other respiratory viruses.
Future COVID-19 vaccination strategies will need to adapt to the evolving epidemiological situation, the possible
emergence of new variants and subvariants of concern, potential seasonality, changing seasonal behaviour and future
waves. In addition, the speed and degree of waning protection against infection and severe outcomes from both vaccineinduced and natural immunity, vaccine effectiveness against BA.4 and BA.5 or new emerging variants, efficacy,characteristics and available supplies of new adapted vaccines, safety considerations around repeated boosting, all play animportant role in determining future long-term vaccination strategies, optimal frequency of revaccination and target groups.

Communication, vaccination acceptance and uptake
considerations for the rollout of vaccination campaigns
Communication initiatives to promote uptake of additional vaccine doses and to promote completion of the primary series
by those who have not yet done so, face several challenges. Some of these challenges are similar to those previously
faced, while others are new:•••Complacency regarding the threat of COVID-19: With restrictions lifted throughout the EU/EEA, many people
may perceive that the pandemic is over. Further, COVID-19 is regarded as a ‘mild’ disease for most people, inparticular in the context of the Omicron variant, and this can add to perceptions that vaccination is not necessary[80]. The fact that many people not yet vaccinated will have undergone an infection can also contribute to lower
vaccination intentions, as this may lead them to underestimate the risk of severe disease if they only faced mild tomoderate symptoms. It is also possible that they might assume that they are permanently immune as a result of theirearlier infection, and/or that they cannot transmit the disease to others [81].
Lower confidence in the effectiveness of the vaccines, and concerns about side effects: Since early 2022,
due to both the circulation of the highly transmissible Omicron variant and waning immunity, the number of COVID19 cases in vaccinated people has increased, although with lower rate of severe disease compared to thoseunvaccinated [1]. As reflected in media coverage [82] and surveys [83], this can lead people to question the value of
COVID-19 vaccines. Such views may be further amplified by misinformation circulating through social media thatinterprets these data as confirmation that vaccines do not work [84]. Further, surveys indicate that people who haveexperienced adverse events of varying degrees after primary vaccination, or who have friends or family members who
had such experiences, may be less inclined to receive a booster [85].
The potential offer of variant-adapted vaccines, and the accompanying timelines, may be confusing forthe public [86] and recurrent boosting faces acceptability challenges: Variant-adapted vaccines are currently
expected to become available during the last trimester of 2022 [87], although the timeline of distribution and numberof doses that will be available are currently being defined with manufacturers. These uncertainties could lead to somevaccines being perceived as ‘better’, or people may decide to adopt a ‘wait and see’ approach to vaccination. Further,
the public may be unclear about who should receive additional boosters when and with which vaccine, as well as
what are the timelines for newer variant-specific vaccines. There are also media reports on the need for vaccines thatoffer more durable protection, while also cautioning that a strategy of booster shots given every few months is notsustainable [88]. Members of the US Advisory Committee on Immunization Practices (ACIP) cautioned in April 2022,
when discussing US strategies for future doses, that for every COVID-19 vaccine dose recommended, uptake has
declined – as shown in vaccine uptake data. ACIP members raised the issue of ‘booster fatigue’ and how it threatens
confidence in the vaccination programme. The impact of each COVID-19 vaccine recommendation on vaccine
confidence and uptake needs to be considered. Further, ACIP discussions highlighted the importance of24

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‘communicating with one voice’ and using common language to explain scientific complexity and uncertainty, in order
to not contribute to the public’s confusion [89].
Within this context, it continues to be very important to monitor vaccine uptake and the associated drivers and barriers tovaccination in order to understand where, why, and in which population groups and communities immunity gaps persist.
As highlighted in previous ECDC reports [1], successful COVID-19 vaccination programmes can only be built on anunderstanding of, and a proper response to individuals’ and communities’ beliefs, concerns and expectations regarding thevaccine and the disease. The ‘5Cs’ model – Confidence, Constraints, Complacency, Calculation, and Collective
responsibility – can be used as a framework for understanding these concerns and designing strategies to facilitate
COVID-19 vaccination acceptance and uptake [90].
To address the public’s doubts about the value of vaccination, clear information should be provided around the rationale
for the recommendations [91] as well as around the benefits of the primary course and boosters for different populationgroups (including for those who already had the disease). Given the evolving nature of the evidence, uncertainty shouldbe acknowledged where it exists [92]. Communication should highlight the protection given by vaccines against the most
severe outcomes of COVID-19, such as hospitalisation and death, which has direct benefits for the individual while also
limiting the burden on healthcare services. In addition, messaging could also emphasise how vaccination can contribute tolimiting the need for any possible re-imposition of restrictions [64]. Further, clear information is needed on which
population groups shall receive boosters, as well as details on the optimal timing (for example, in relation to if/when theyreceived a previous booster dose). Targeted communication should be provided to the specific groups being
recommended for the boosters, as well as to healthcare workers so they can give reccomendations to their patients. Thiscan also include information on the possibility for combining uptake of COVID-19 vaccine with the seasonal influenza
vaccine. Information voids or misunderstandings regarding the types of vaccines that are available along with possible
timelines for the availability of adapted vaccines need to be addressed. Barriers to uptake, specifically including thoserelated to physical access, also need to be identified and addressed. Planning of future campaigns should be based ongood practices identified during earlier phases of the vaccination programme.
Throughout the vaccination programme, countries have reported adopting a range of strategies to reach individuals andpopulation groups with low vaccination uptake. These have included measures related to addressing, among other issues,
access, misinformation, distrust, or a lack of clear and suitably adapted information. For example, access has been
facilitated through use of mobile and pop-up vaccination teams/clinics; targeted communication strategies have been
adopted; reminders have been sent; outreach initiatives and intersectoral partnerships for community-based interventions
have been implemented; and vaccine ambassadors have been used to promote vaccination within their own communities [93].

Knowledge gaps and research priorities
Further or continued research in the following areas should be a matter of public health priority:
•

•

•
•
•

Studies and collection of real-life data on longer-term duration of protection and patterns of waning protection against
severe outcomes following first and second booster doses in different population groups, especially in older age
groups (in response to currently circulating BA.4/BA.5 and potential future SARS-CoV-2 variants) as well as
immunosuppressed individuals, and those with underlying conditions associated with more severe COVID-19
outcomes;
Nationally representative, age-stratified sero-epidemiological studies provide a basis for estimating the proportion of
the population with pathogen-specific antibodies in a given country. Such studies are particularly informative when
they apply functional (neutralising titres) or quantitative assays to determine the level of both natural and vaccineinduced antibodies in participating individuals in order to estimate the contribution of natural, vaccine-derived andhybrid immunity in the population. Given that serum antibodies wane over time, longitudinal or repeated studies withthe same sampling strategy and common testing methodology are essential for understanding temporal trends. Highquality studies on the current sero-epidemiological situation in different EU/EEA countries will be crucial for highquality modelling predictions, including an understanding of optimal rollout timing for future vaccine boosters.
Kinetics of the antibody response to repeated COVID-19 vaccine doses in different populations;
Effectiveness of eventual future variant-specific vaccines compared to currently available vaccines;•
Continuous monitoring of safety following additional booster doses;•
Vaccine effectiveness studies that disaggregate findings by prior infection status;
Vaccine effectiveness for individuals receiving mRNA vaccine booster doses following administration of a primary
vaccine series with another type of vaccine (i.e. viral vector) and for boosters with non-mRNA vaccines.

Consulted experts (in alphabetical order)
ECDC experts: Kim Brolin, Nick Bundle, Rok Grah, John Kinsman, Gaetano Marrone, Kate Olsson, Ajibola Omokanye, Rene
Niehus, Lucia Pastore Celentano, Anastasia Pharris, Bastian Prasse, Giovanni Ravasi, Frank Sandmann, Nataliia
Tsekhmestruk, Karin Wilbe Ramsay, Andrea Würz.
European Medicines Agency: Marco Cavaleri

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59. Stringhini S, Zaballa M-E, Pullen N, Perez-Saez J, de Mestral C, Loizeau AJ, et al. Seroprevalence of anti-SARS-CoV-2
antibodies 6 months into the vaccination campaign in Geneva, Switzerland, 1 June to 7 July 2021. Euro Surveill.
2021;26(43):2100830. Available at: https://www.eurosurveillance.org/content/10.2807/15607917.ES.2021.26.43.2100830
60. Chia WN, Zhu F, Ong SWX, Young BE, Fong S-W, Le Bert N, et al. Dynamics of SARS-CoV-2 neutralising antibody
responses and duration of immunity: a longitudinal study. The Lancet Microbe. 2021;2(6):e240-e9. Available at:https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(21)00025-2/fulltext
61. Brown PE, Fu SH, Bansal A, Newcombe L, Colwill K, Mailhot G, et al. Omicron BA. 1/1.1 SARS-CoV-2 Infection among
Vaccinated Canadian Adults. New England Journal of Medicine. 2022;386:2337-9. Available at:https://www.nejm.org/doi/10.1056/NEJMc2202879
62. European Centre for Disease Prevention and Control (ECDC). COVID-19 Vaccine Tracker. Stockholm: ECDC; 2022.
Available at: https://vaccinetracker.ecdc.europa.eu/
63. Superior Health Council (SHC). COVID-19 Vaccination: Autumn/Winter season 2022-2023 - N. 9721. Brussels: SHC;
2022. Available at:https://www.health.belgium.be/sites/default/files/uploads/fields/fpshealth_theme_file/20220706_shc-9721_covid19_booster_automn-winter_2022-2023_vweb.pdf
64. Sundhedsstyrelsen. Efteråret byder på vaccinationer, så vi er klar til en vinter med covid-19, influenza og
pneumokoksygdom. Copenhagen: Sundhedsstyrelsen; 2022. Available at:https://www.sst.dk/da/Nyheder/2022/Efteraaret-byder-paa-vaccinationer
65. Public Health Agency of Sweden. Nya rekommendationer inför höstens vaccinationer mot covid-19. Solna: Public
Health Agency of Sweden; 2022. Available at: https://www.folkhalsomyndigheten.se/nyheter-ochpress/nyhetsarkiv/2022/maj/nya-rekommendationer-infor-hostens-vaccinationer-mot-covid-19/
66. US Food and Drug Administration (FDA). FDA Briefing Document. Vaccines and Related Biological Products Advisory
Committee Meeting June 28, 2022. Washington: FDA; 2022. Available at:https://www.fda.gov/media/159452/download
67. European Medicines Agency (EMA). Start of rolling review for adapted Comirnaty COVID-19 vaccine. Amsterdam: EMA;
2022. Available at: https://www.ema.europa.eu/en/news/start-rolling-review-adapted-comirnaty-covid-19-vaccine

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68. European Medicines Agency (EMA). Start of rolling review for adapted Spikevax COVID-19 vaccine. Amsterdam: EMA;
2022. Available at: https://www.ema.europa.eu/en/news/start-rolling-review-adapted-spikevax-covid-19-vaccine
69. World Health Organization (WHO). Interim statement on the composition of current COVID-19 vaccines. Geneva:
WHO; 2022. Available at: https://www.who.int/news/item/17-06-2022-interim-statement-on--the-composition-ofcurrent-COVID-19-vaccines
70. European Medicines Agency (EMA). Global regulators agree on key principles on adapting vaccines to tackle virus
variants. News 01/07/2022. Amsterdam: EMA; 2022. Available at: https://www.ema.europa.eu/en/news/globalregulators-agree-key-principles-adapting-vaccines-tackle-virus-variants
71. Khoury DS, Cromer D, Reynaldi A, Schlub TE, Wheatley AK, Juno JA, et al. Neutralizing antibody levels are highly
predictive of immune protection from symptomatic SARS-CoV-2 infection. Nature medicine. 2021;27(7):1205-11.
Available at: https://www.nature.com/articles/s41591-021-01377-8
72. Andrews N, Stowe J, Kirsebom F, Toffa S, Rickeard T, Gallagher E, et al. Covid-19 vaccine effectiveness against the
Omicron (B. 1.1. 529) variant. New England Journal of Medicine. 2022;386(16):1532-46. Available at:https://www.nejm.org/doi/full/10.1056/NEJMoa2119451
73. UK Health Security Agency (UKHSA). COVID-19 vaccine surveillance report Week 1, 6 January 2022. London: UKHSA;
2022. Available at:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1045329/Vaccine_s
urveillance_report_week_1_2022.pdf
74. Collie S, Champion J, Moultrie H, Bekker L-G, Gray G. Effectiveness of BNT162b2 vaccine against omicron variant inSouth Africa. New England Journal of Medicine. 2022;386(5):494-6. Available at:https://www.nejm.org/doi/full/10.1056/NEJMc2119270
75. Sheikh A, Kerr S, Woolhouse M, McMenamin J, Robertson C. Severity of Omicron variant of concern and vaccine
effectiveness against symptomatic disease: national cohort with nested test negative design study in Scotland. The
University of Edinburgh [Preprint]. 2021. Available at: https://www.research.ed.ac.uk/en/publications/severity-ofomicron-variant-of-concern-and-vaccine-effectiveness-?fbclid=IwAR1qHNz_yVl6KVtg7oq0XESOXj9o5m9i9cxIE1r11LYZ787xdHHwj8nF_Q
76. Gray GE, Collie S, Garrett N, Goga A, Champion J, Zylstra M, et al. Vaccine effectiveness against hospital admission inSouth African health care workers who received a homologous booster of Ad26. COV2 during an Omicron COVID19
wave: Preliminary Results of the Sisonke 2 Study. medRxiv [Preprint]. 2021. DOI: 10.1101/2021.12.28.21268436v1.
Available at: https://www.medrxiv.org/content/10.1101/2021.12.28.21268436v1
77. European Centre for Disease Prevention and Control (ECDC). European Covid-19 Forecast Hub. Stockholm: ECDC;
2021. Available at: https://covid19forecasthub.eu/index.html
78. Suetens C, Kinross P, Gallego Berciano P, Arroyo Nebreda V, Hassan E, Calba C, et al. Increasing risk of breakthrough
COVID-19 in outbreaks with high attack rates in European long-term care facilities, July to October 2021.
Eurosurveillance. 2021;26(49):2101070. Available at: https://www.eurosurveillance.org/content/10.2807/15607917.ES.2021.26.49.2101070
79. Munro AP, Feng S, Janani L, Cornelius V, Aley PK, Babbage G, et al. Safety, immunogenicity, and reactogenicity of
BNT162b2 and mRNA-1273 COVID-19 vaccines given as fourth-dose boosters following two doses of ChAdOx1 nCoV19 or BNT162b2 and a third dose of BNT162b2 (COV-BOOST): a multicentre, blinded, phase 2, randomised trial. The
Lancet Infectious Diseases [Preprint]. 2022. DOI: 10.1016/S1473-3099(22)00271-7. Available at:https://www.sciencedirect.com/science/article/pii/S1473309922002717
80. University of Erfurt. Ergebnisse aus dem COVID-19 Snapshot MOnitoring COSMO: Die psychologische Lage. Universityof Erfurt; 2022. Available at: https://projekte.uni-erfurt.de/cosmo2020/files/COSMO_W61.pdf
81. Sprengholz P, Betsch C. Previous SARS-CoV-2 infection is linked to lower vaccination intentions. Journal of Medical
Virology. 2021 2021/12/01;93(12):6456-7. Available at: https://doi.org/10.1002/jmv.27221
82. Myhrén L. Godmorgon Världen: Vaccintrötthet bland de äldre. Stockholm: Sveriges Radio; 26 June 2022. Available at:https://www.ema.europa.eu/en/news/global-regulators-agree-key-principles-adapting-vaccines-tackle-virus-variants
83. Kaiser Family Foundation (KFF). COVID-19 Vaccine Monitor Dashboard. San Fransisco: KFF; 2021. Available at:https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-monitor-dashboard/#boosters
84. Spencer SH. COVID-19 Vaccines Reduce Hospitalization and Death Rates, Contrary to Social Media Claims.
FactCheck.org; 14 April 2022. Available at: https://www.factcheck.org/2022/04/scicheck-covid-19-vaccines-reducehospitalization-and-death-rates-contrary-to-social-media-claims/
85. Babicki M, Mastalerz-Migas A. Attitudes of Poles towards the COVID-19 Vaccine Booster Dose: An Online Survey in
Poland. Vaccines. 2022;10(1) Available at: https://pubmed.ncbi.nlm.nih.gov/35062729/

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86. Achenbach J. JC. Boost now? Boost later? Tricky calculation for a 4th coronavirus shot. The Washington Post. 2022 20
April 2022 Available at: https://www.washingtonpost.com/health/2022/04/20/when-to-get-second-covid-booster/
87. European Medicines Agency (EMA). EMA regular press briefing, 2 June 2022. Amsterdam: EMA; 2022. Available at:https://www.youtube.com/watch?v=ml0G44-poR8
88. Armour S. WL. Can We Develop a Covid-19 Vaccine That Lasts? . The Wall Street Journal. 17 June 2022 Available at:https://www.wsj.com/articles/can-we-develop-a-covid-19-vaccine-that-lasts11655478373?mod=Searchresults_pos2&page=1
89. Centers for Disease Control and Prevention (CDC). April 20, 2022 ACIP Meeting - Public Comment. YouTube. 25 April
2022. Available at: https://www.youtube.com/watch?v=Pwws698bH2s
90. European Centre for Disease Prevention and Control (ECDC). Facilitating COVID-19 vaccination acceptance and uptake
in the EU/EEA. Stockholm: ECDC; 2021. Available at: https://www.ecdc.europa.eu/en/publications-data/facilitatingcovid-19-vaccination-acceptance-and-uptake
91. Robert Koch Institut. COVID-19 Impfempfehlung (Status 24.5.2022). Accessed 27 June 2022. Available at:https://www.rki.de/SharedDocs/FAQ/COVID-Impfen/FAQ_Liste_STIKO_Empfehlungen.html. Berlin: RKI; 2021.
Available at: https://www.rki.de/SharedDocs/FAQ/COVID-Impfen/FAQ_Liste_STIKO_Empfehlungen.html
92. Sopory P, Day AM, Novak JM, Eckert K, Wilkins L, Padgett DR, et al. Communicating Uncertainty During Public Health
Emergency Events: A Systematic Review. Review of Communication Research. 2020 07/09;7:67-108. Available at:https://rcommunicationr.org/index.php/rcr/article/view/45
93. European Centre for Disease Prevention and Control (ECDC). Overview of the implementation of COVID-19 vaccination
strategies and vaccine deployment plans in the EU/EEA, 21 April 2022. Stockholm: ECDC; 2022. Available at:https://www.ecdc.europa.eu/en/publications-data/overview-implementation-covid-19-vaccination-strategies-anddeployment-plans

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Annex 1. Evaluating the impact of later and/or
faster second booster rollout scenarios
Figure A1. Comparison of the second booster rollout scenario starting on 18 July 2022 and later second
booster scenarios (starting on 1 August 2022, 1 September 2022 and 1 October 2022, respectively) withrespect to the predicted vaccine effectiveness against hospitalisation, averaged across all individuals older
than 60 years

The top and bottom rows correspond to countries with a high and low first booster uptake (of more or less than 40% of the total
population, respectively, on 1 July 2022). The predictions for each EU/EEA country and for each uncertain spreading parameter fall within
the respective shaded area, and the solid line is the respective mean across the predictions of the considered EU/EEA countries andparameter uncertainties.

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Preliminary public health considerations for COVID-19 vaccination strategies in the second half of 2022

Figure A2. Comparison of the booster rollout scenario starting on 18 July 2022, where the eventual second
booster uptake is attained in the same time as for the first booster uptake of the respective country, andfast booster rollouts that achieve the eventual second booster uptake within six weeks (from 1 September
2022 to 15 October 2022, and from 1 October 2022 to 15 November 2022, respectively) with respect to thepredicted vaccine effectiveness against hospitalisation, averaged across all individuals older than 60 years

The top and bottom rows correspond to countries with a high and low first booster uptake (of more or less than 40% of the total
population, respectively, on 1 July 2022). The predictions for each EU/EEA country and for each uncertain spreading parameter fall within
the respective shaded area, and the solid line is the respective mean across the predictions of the considered EU/EEA countries andparameter uncertainties.

33

Annex 2 – Policies on additional and booster doses in EU/EEA
countries
Table A1. Recommendations for additional and booster doses in EU/EEA countries (n=30)
Country

Recommendation and timing of additional doses and booster doses of
COVID-19 vaccination for individuals with weakened immune systems(i.e. immunocompromised and immunosuppressed)

Recommendation for booster doses of COVID-19 vaccination andtiming for the general population

References

Austria

Recommendation:
Additional dose plus one booster dose (four doses) for individuals ≥12 years(extended primary three-dose vaccination series plus a booster dose 3+1
schedule).
Timing:Additional dose is given at least 28 days after second dose. At least fourweeks later, testing of neutralising antibodies is recommended to find out
whether any immune response has occurred. If no neutralising antibodies
can be detected after the additional third dose, an additional fourth dose isrecommended at least four weeks after the third dose (off-label). In the eventof a negative neutralising antibody test at least four weeks after the third
dose, administration of an additional fourth dose is recommended (off-label).

Bundesministerium für Soziales Gesundheit Pflege undKonsumentenschutz. COVID-19-Impfungen:
Anwendungsempfehlungen des Nationalen Impfgremiums.
2021. Available at: https://www.sozialministerium.at/CoronaSchutzimpfung/Corona-Schutzimpfung---Fachinformationen.html

Belgium

Recommendation:
Additional dose for individuals aged 5-11 years (extended primary threedose vaccination series).
One booster dose (fourth dose) for individuals >12 years (extended primary
three-dose vaccination series plus a booster dose).
Timing:Additional dose given at least 28 days after second dose followed by abooster dose (fourth dose) at least three months after the third dose.
Recommendation:
Additional dose for individuals (extended primary three-dose vaccination
series).
Timing:Additional dose given at least 28 days after second dose.

Recommendation:
One booster dose for individuals ≥5 years (primary two-dose vaccination
series plus a booster dose).
Two booster doses for individuals aged ≥80 years; for persons with
underlying health conditions or at risk for severe disease (from 12 years) andthose 65-79 years according to a medical individual benefit -risk assessment
or at the explicit request of the person to be vaccinated (two dose primary
vaccination series plus two booster doses).
Timing:Individuals aged five years and above: booster given as of six months after
the second dose; After one dose with COVID-19 Vaccine Janssen a second
dose is recommended 28 days after the first dose (preferably with mRNAvaccine), COVID-19 Vaccine Janssen can also be used again for the second
dose, in this case an interval of at least two months between the first two
doses is recommended and a third dose at the above-indicated intervals (sixmonths) is also recommended for people vaccinated with COVID-19 Vaccine
Janssen.
Two booster doses (fourth doses) can be considered four months after thethird dose at the earliest, but in any case, six months after the third dose forthose ≥80 years. For people aged ≥65 years and persons regardless of age(12 years or older) with pre-existing conditions and circumstances that may
place them at increased risk for severe disease of COVID-19, in whom anearlier waning of immunity is to be expected - six months after the first
booster (third dose)– off-label
Recommendation:
One booster dose for individuals aged ≥18 years (primary two-dose
vaccination series plus a booster dose).
Timing:Booster given at least four months after primary vaccination with mRNAbased vaccines; four months after primary vaccination with Vaxzevria; twomonths after single dose of COVID-19 Vaccine Janssen.
Recommendation:
One booster dose for individuals age ≥12 years (primary two-dose
vaccination series plus a booster dose).
Timing:Booster dose given at least three months after primary vaccination for those
aged ≥18 years. For those aged 12-17 years, at least six months after
primary vaccination.
Recommendation:

Unified Information Portal Bulgaria. Guidelines for administering
an additional or booster dose of COVID-19 vaccine are provided
by the Expert Advisory Board on Immunoprophylaxis
Surveillance. 2021. Available at:https://coronavirus.bg/bg/news/2513#

Bulgaria

Croatia

Recommendation:
Additional dose plus one booster dose (four doses) for individuals aged ≥5years (extended primary three-dose vaccination series plus a booster dose).

Belgium Superior Health Council. Available at:https://www.health.belgium.be/en/superior-health-council

Croatian Institute for Public Health. Preporuke za primjenu treće
doze u imunokompromitiranih osoba i docjepljivanje protiv
bolesti COVID-19. 2021. Available at: https://www.hzjz.hr/wp-

Country

CyprusRecommendation and timing of additional doses and booster doses of
COVID-19 vaccination for individuals with weakened immune systems(i.e. immunocompromised and immunosuppressed)

Recommendation for booster doses of COVID-19 vaccination andtiming for the general population

References

Timing:Additional dose given at least eight weeks after second dose, followed by abooster dose at least three months after the additional dose.

One booster dose for individuals ≥18 years (primary two-dose vaccination
series plus a booster dose). Also recommended for children aged 12 years
and over with underlying risk factors and at increased risk of severe disease.
Two booster doses for individuals ≥80 years and residents and staff in LTCF
who are over 65 years and health professionals. Also recommended for
those at increased risk of developing severe disease and those vaccinatedwith Janssen.
Timing:First booster dose given at least three months after primary vaccination; twomonths after single dose of COVID-19 Vaccine Janssen.
Second booster dose given at least four months after the first booster dose.
Recommendation:
One booster dose for individuals aged ≥12 years (two dose primary
vaccination series with mRNA-based vaccines plus booster dose with
Comirnaty).
Two booster doses given to those aged >60 years, residents and staff at
LTCF, vulnerable groups (i.e. individuals with diabetes mellitus, and severe
obesity), healthcare professionals (two dose primary vaccination series plus
two booster doses (second booster dose with mRNA-based vaccines)).
Timing:First booster dose given at least five months and two weeks after primary
vaccination, second booster dose at least five months after the first booster
dose.
Recommendation:
One booster dose for individuals aged ≥12 years (two dose primary
vaccination series plus booster dose).
Timing:Booster dose given at least three months after primary vaccination for those
aged >60 years, LTCF residents and staff, healthcare workers and people withchronic conditions. For the rest of the population five months after primary
vaccination. Two months after single dose of COVID-19 Vaccine Janssen.
Recommendation
Three doses for individuals aged ≥18 years (2 dose primary vaccination
series plus booster dose).
4th dose as a second booster is recommended to specific target groups.

content/uploads/2020/03/Preporuke-za-primjenu-tre%C4%87edoze-u-imunokompromitiranih-osoba-i-docjepljivanje-protivbolesti-COVID-19.pdf
https://cijepise.zdravlje.hr/

Recommendation:
Additional dose plus one booster dose (four doses) for individuals
irrespective of age (extended primary three-dose vaccination series plus abooster).
Timing:Additional dose given at least four weeks after second dose followed by abooster dose at least five months after the third dose.

Czechia

Recommendation:
Additional dose for individuals (extended primary three-dose vaccination
series).
Timing:Additional dose given at least one month after second dose.

Denmark

Recommendation:
Additional dose plus one booster dose for individuals (extended primary
three-dose vaccination series plus a booster).
Timing:Additional dose given at least one month after second dose and a maximumof eight months afterwards or at earliest convenience (different timings
depending on the risk group) followed by a booster dose at least threemonths after the third dose.
Recommendation:
Additional dose for individuals (extended primary three-dose vaccination
series).
Timing:Additional dose given at least one month after second dose.

Estonia

Republic of Cyprus Ministry of Health. COVID-19 Vaccines andTreatment Protocols. 2022. Available at:https://www.pio.gov.cy/coronavirus/eng/categories/vaccines-en

The Ministry of Health of the Czech Republic. Booster andadditional dose. 2021. Available at:https://covid.gov.cz/en/situations/register-vaccination/boosterand-additional-dose

Danish Health Authority. Booster vaccination against COVID-19.
2021. Available at: https://www.sst.dk/en/English/Coronaeng/Vaccination-against-COVID-19/Booster-vaccination

Timing:Booster given at least 140 days after primary vaccination.
Recommendation:
One booster dose for individuals aged ≥18 years (two dose primary
vaccination series plus booster dose).
Timing:Booster given at least three months after primary vaccination with mRNAbased vaccines; and Vaxzevria; two months after single dose vaccination
with COVID-19 Vaccine Janssen. Recovered individuals – five months after
recovery.
Two booster doses 60+ individuals and individuals 12+ with certain
diagnosis; elderly care/nursing houses (residents and care providers who

Terviseamet. https://vaktsineeri.ee/covid-19/lahenvaktsineerima/

Country

Recommendation and timing of additional doses and booster doses of
COVID-19 vaccination for individuals with weakened immune systems(i.e. immunocompromised and immunosuppressed)

Finland

Recommendation
Additional dose plus a booster dose for individuals aged >12 years(extended primary three-dose vaccination series plus a booster dose).
Timing:Additional dose given at least two months after second dose followed by abooster dose at least 3-4 months after the third dose.

FranceRecommendation
Additional dose plus a booster dose for individuals (extended primary threedose vaccination series plus a booster dose).
Timing:Additional dose given at least one month after second dose, followed by abooster dose as least three months after the third dose.

Germany

Recommendation
Additional dose plus two booster doses for individuals aged ≥5 years(extended primary three-dose vaccination series plus two booster doses).
Immunocompromised individuals:
Additional dose is given at least one month after the second dose followed
by a booster dose given at least three months after the third dose.

Recommendation for booster doses of COVID-19 vaccination andtiming for the general population

are in direct contact with patients); health care providers who are in directcontact with patients
Recommendation:
One booster dose for individuals aged ≥18 years and persons aged 12-17
years in risk groups (two dose primary vaccination series plus booster dose).
Two booster doses for individuals aged ≥80 years, residents of LTCFs, older
people receiving home care or informal care (two dose primary vaccination
series plus two booster doses).
Timing:One booster dose given to those over 60 years of age and at-risk groups
aged over 18 years is recommended 3-4 months after primary course. For
persons between 18 and 60 years of age, a booster dose is recommended
4-6 months after primary course. In 12–17-year-olds six months after
primary course. For those vaccinated with Janssen vaccine, a booster doseis recommended two months after the primary course.
Second booster dose given at least three months after the first booster dose.
Recommendation:
One booster dose for individuals aged ≥12 years (two dose primary
vaccination series, plus booster dose).
Two booster doses for individuals aged ≥80 years, residents of LTCFs aged
≥65 years who are at risk of severe disease (two dose primary vaccination
series plus two booster doses after 3 months).
Two booster doses for individuals aged ≥60 years and < 80 years (with orwithout comorbidities) 6 months after the first booster or infection.
General population:
Booster dose given at least three months after primary vaccination and asecond booster dose given at least six months after the first booster dose.
Recommendation:
One booster dose for all individuals aged ≥12 years and for 5- to 11-yearolds at increased risk of severe illness (two dose primary vaccination seriesplus booster dose).
Two booster doses for individuals aged >70 years, residents of LTCFs andpeople at risk of developing severe illness in support facilities, workers inmedical and nursing facilities (especially those in direct contact with patientsand residents) (two dose primary vaccination series plus two booster doses).
Timing:Booster dose given at least three months after primary vaccination for those≥12 years. For 5–11-year-olds, booster dose given at least six months after
primary vaccination. Second booster dose at least three months after first
booster dose for those at risk. For personnel in medical and nursing
facilities, second booster dose given at least six months after the first
booster dose.
For those vaccinated with COVID-19 Vaccine Janssen, a second dose with
an mRNA vaccine is recommended one month after primary course to
optimise immunisation. A booster of mRNA should follow after at least threemonths.

References

Terveyden ja hyvinvoinnin laitos. Kolmas koronarokoteannos.
2022. Available at: https://thl.fi/fi/web/infektiotaudit-jarokotukset/rokotteet-a-o/koronavirusrokotteet-eli-covid-19rokotteet-ohjeita-ammattilaisille/kolmas-koronarokoteannos

Haute Autorité de santé. Covid-19 : un second rappel réservé aux
personnes les plus à risques. 2022. Available at: https://www.hassante.fr/jcms/p_3325021/fr/covid-19-un-second-rappel-reserve-auxpersonnes-les-plus-a-risquesConseil d’orientation de la stratégie vaccinale. Available at : cosv__addendum_du_18_fevrier_2022_a_l_avis_du_19_janvier_2022__deuxieme_dose_de_rappel_vaccinal-2.pdf (solidaritessante.gouv.fr)
Ministery of Health. Available at: https://solidaritessante.gouv.fr/IMG/pdf/dgs-urgent_no_2022_47_2eme_rappel_60_2.pdf
Epidemiologisches Bulletin 21/2022, STIKO: 20. Aktualisierung
der COVID-19-Impfempfehlung. Tab. 5 | Empfehlungen zu
Indikationsgruppen, Impfstoffen und Impfabständen zur 2.
Auffrischimpfung gegen COVID-19 (Stand: 24.05.2022).
Available at:https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2022/Ausg
aben/21_22.pdf?__blob=publicationFile

Country

Recommendation and timing of additional doses and booster doses of
COVID-19 vaccination for individuals with weakened immune systems(i.e. immunocompromised and immunosuppressed)

Recommendation for booster doses of COVID-19 vaccination andtiming for the general population

References

GreeceRecommendation
Additional dose plus one booster dose for individuals aged ≥12 years(extended primary three-dose vaccination series plus a booster dose).
Timing:Additional dose given at least four weeks after second dose, followed by abooster dose at least three months after the third dose.

Recommendation:
One booster dose for individuals aged ≥18 years (two dose primary
vaccination series plus booster dose).
Two booster doses for those aged ≥60 years.
Timing:One booster dose given at least three months after primary vaccination. Twomonths after primary vaccination with COVID-19 Vaccine Janssen. Second
booster dose at least four months after first booster dose.

Hungary

Recommendation:
Additional dose plus one booster dose for individuals (extended primary
three-dose vaccination series plus a booster dose).
Timing:Additional dose given at least 28−56 days after second dose, followed by abooster dose at least four months after third dose.

Iceland

Recommendation:
Additional doses for individuals (extended primary three-dose vaccination
series).
Timing:Additional dose given at least three months after second dose.

Ireland

Recommendation:
Additional doses for individuals aged 5-11 years (extended primary threedose vaccination series).
Additional dose plus one booster dose for individuals aged ≥12 years(extended primary three-dose vaccination series plus one booster dose).
Timing:Additional dose given at least two months after second dose for those aged
≥12 years and 28 days after second dose for those aged 5-11 years.
Booster dose given to those aged ≥12 years at least three months after thethird dose.
Recommendation:
Additional dose plus a booster dose for individuals (extended primary threedose vaccination series plus a booster dose).
Timing:Additional dose given at least 28 days after second dose, followed by abooster dose fourth months after third dose.
A second booster: 120 days from the first booster dose

Recommendation:
One booster dose for individuals aged ≥12 years (two dose primary
vaccination series plus booster dose).
Two booster doses for the elderly, and those with chronic disease and alsoavailable to anyone who asks for it (two dose primary vaccination series plus
two booster doses).
Timing:One booster dose given at least four months after primary vaccination
followed by a second booster dose at least four months after first booster
dose.
Recommendation:
One booster dose for individuals ≥16 years (two dose primary vaccination
series plus booster dose).
A fourth dose has been recommended for those persons 65 and over with
an mRNA vaccine.
Timing:Booster dose given at least five months after second dose.
Recommendation:
One Booster dose doses for individuals aged ≥12 years (two dose primary
vaccination series plus booster dose).
Two booster doses for those aged ≥65 years (two dose primary vaccination
series plus two booster doses).
Timing:One booster dose is given to those aged >16 years at least three months
after the primary vaccination and for 12–15-year-olds the booster dose isgiven at least six months after the primary vaccination dose.
Second booster dose given at least four months after first booster dose.
Recommendation:
One booster dose for individuals aged ≥12 years (two dose primary
vaccination series plus booster dose).
Two booster doses for people aged 80 and over, LTCF residents, people
with high fragility motivated by pathologies concomitant / pre-existing aged
60 years and over
Timing:One booster dose given at least four months after primary vaccination.
A second booster: 120 days from the first booster dose

Briefing by the President of the National Vaccination Committee
Maria Theodoridou and the Secretary General Primary HealthCare Mario Themistocleous. 2022. Available at:https://www.moh.gov.gr/articles/ministry/grafeio-typoy/pressreleases/10335-enhmerwsh-diapisteymenwn-syntaktwn-gia-toethniko-sxedio-emboliastikhs-kalypshs-kata-ths-covid-19-apothn-proedro-ths-ethnikhs-epitrophs-emboliasmwn-mariatheodwridoy-kai-ton-g-g-prwtobathmias-frontidas-ygeias-mariothemistokleoys
Hungary Ministry of Interior.
https://koronavirus.gov.hu/sites/default/files/sites/default/files/im
ce/nnk_eljarasrend_2022.01.14._negyedik_oltas.pdf

Italy

Iceland Directorate of Health. Early booster vaccination for
COVID-19. 2022. Available at: https://www.landlaeknir.is/umembaettid/greinar/grein/item48474/early-booster-vaccination-forcovid-19

Ireland Department of Health. COVID-19 vaccine booster dose.
2022. Available at: https://www2.hse.ie/screening-andvaccinations/covid-19-vaccine/get-the-vaccine/covid-19-vaccinebooster-dose/

Ministry of Health, Italy. COVID-19 vaccine plan. 2022. Available
at:https://www.salute.gov.it/portale/nuovocoronavirus/dettaglioCont
enutiNuovoCoronavirus.jsp?lingua=italiano&id=5452&area=nuo
voCoronavirus&menu=vuoto
Ministry of Health, Italy. Directorate-General for HealthPrevention. Indications on the administration of the second
booster dose (second booster) as part of the anti SARS-CoV-2 /COVID-19 vaccination campaign. 2022. Available at:https://www.trovanorme.salute.gov.it/norme/renderNormsanPdf?
anno=2022&codLeg=86755&parte=1%20&serie=null

Country

Recommendation and timing of additional doses and booster doses of
COVID-19 vaccination for individuals with weakened immune systems(i.e. immunocompromised and immunosuppressed)

Recommendation for booster doses of COVID-19 vaccination andtiming for the general population

References

LatviaRecommendation:
Additional dose plus a one booster dose for individuals (extended primary
three-dose vaccination series plus a booster dose).
Timing:Additional dose given at least one month after second dose.

Recommendation:
One booster dose for individuals aged ≥18 years (two dose primary
vaccination series plus booster dose).
A second booster is under consideration.

Latvia National Council for Immunization. 2022. Available at:https://www.vmnvd.gov.lv/lv/media/15326/download

Liechtenstein

Lithuania

Recommendation:
Additional dose for individuals (extended primary three-dose vaccination
series).
Timing:Additional dose given at least 28 days after second dose.
Recommendation:
Additional dose for individuals (extended primary three-dose vaccination
series).
Timing:Additional dose given at least 28 days after second dose.

Luxembourg

Recommendation:
Additional dose plus a one booster dose for individuals aged ≥18 years(extended primary three-dose vaccination series plus a booster dose).
Timing:Additional dose given at least 12 weeks after second dose followed by a booster
dose at least three months after the third dose.

Malta

Recommendation:
Additional dose plus a one booster dose for individuals (extended primary
three-dose vaccination series plus a booster dose).
Timing:Additional dose given at least 28 days after second dose.

the Netherlands

Recommendation:
Additional dose plus a booster dose for individuals (extended primary threedose vaccination series plus a booster dose).
For the immunocompromised population 12+: a third dose is recommended
as part of the primary series, as well as a fourth dose as a first booster.
For the immunocompromised population 18+: a fourth dose is recommended
as a first booster, a fifth dose is recommended as a second booster.
Timing:An additional/third dose at least four weeks after second dose;followed by abooster dose at least three months after third dose;followed by a second
booster dose at least three months after the fourth dose.

Timing:Booster dose given at least three months after primary vaccination with mRNA
vaccines. Two months after single dose of COVID-19 Vaccine Janssen. Threemonths after primary vaccination with Vaxzevria.
Recommendation:
One booster dose for individuals ≥12 years (two dose primary vaccination
series plus booster dose).
Timing:Booster dose given at least four months after primary vaccination.
Recommendation:
One booster dose for individuals aged ≥18 years (two dose primary
vaccination series plus booster dose).
Timing:Booster dose given at least 90 days months after primary vaccination; 60 days
after single dose of COVID-19 Vaccine Janssen.
Recommendation:
One booster dose for individuals aged ≥12 years (two dose primary
vaccination series plus booster dose).
Two booster doses for people aged 80 and over
Timing:Booster dose given at least three months after primary vaccination with mRNA-based
vaccines; four months after primary vaccination with Vaxzevria; one month after
single dose of COVID-19 Vaccine Janssen followed by an optional third dose at least
three months after the second dose.
Second booster dose at least four months after the first booster dose.
Recommendation:
One booster dose for individuals ≥18 years (2 dose primary vaccination
series plus booster dose).
Second booster dose to the elderly over the age 65, residence of nursing
homes.
Timing:Booster dose given at least three months after primary vaccination.
Recommendation:
One booster dose for individuals 18-59 years (two dose primary vaccination
series plus booster dose).
Two booster doses for individuals aged ≥60 years, residents in LTCFs,
adults with Down syndrome (two dose primary vaccination series plus twobooster doses).
Timing:One booster dose at least three months after primary vaccination, followed
by a second booster dose at least three months after the first booster dose.

Swiss Federal Office of Public Health FOPH. Coronavirus:
Vaccination. Available at:https://www.bag.admin.ch/bag/en/home/krankheiten/ausbrueche-epidemien-pandemien/aktuelle-ausbrueche-epidemien/novelcov/impfen.html#-1386562885
Minister of Health of the Republic of Lithuania. Regarding theapproval of the description of the procedure for the organizationof COVID-19 disease (coronavirus infection) vaccine purchasedfrom the state budget at the expense of vaccination of the
population. 2022. Available at: https://eseimas.lrs.lt/portal/legalAct/lt/TAD/f735b430469711ebb394e1efb
98d3e67/asr
The Luxembourg Government. Coronavirus vaccination. 2022.
Available at: https://covid19.public.lu/en/vaccination.html
Conseil supérieur des maladies infectieuses. 3 March 2022.
Available at : CONSEIL SUPERIEUR D’HYGIENE (public.lu)
Coneil supérieur des maladies infectieuses. 12 April 20222.
Available at : recommandation-4e dose (public.lu)

Malta Ministry of health. Vaccines. 2022. Available at:https://deputyprimeminister.gov.mt/en/health-promotion/covid19/Pages/vaccines.aspx

The Netherlands - National Institute for Public Health and theEnvironment. Who can get a booster vaccination and when?
2022. Available at:https://www.government.nl/topics/coronavirus-covid-19/dutchvaccination-programme/booster-vaccination
Netherlands. National Institute for Public Health and theEnvironment. Repeat shot against corona (2nd booster). 2022.
Available at:https://www.rijksoverheid.nl/onderwerpen/coronavirusvaccinatie/aanpak-coronavaccinatie/herhaalprik

Country

Recommendation and timing of additional doses and booster doses of
COVID-19 vaccination for individuals with weakened immune systems(i.e. immunocompromised and immunosuppressed)

Recommendation for booster doses of COVID-19 vaccination andtiming for the general population

References

NorwayRecommendation:
Additional dose plus a booster dose for individuals (extended primary threedose vaccination series plus a booster dose).
Third booster dose (dose 5): recommended for people with severely
weakened immune systems
Timing:Additional dose given at least four weeks after second dose, followed by a booster
dose at least three months after the third dose.
Interval of minimum three months

Norwegian Institute of Public Health. Booster doses. 2022. Available
at: https://www.fhi.no/en/id/vaccines/coronavirus-immunisationprogramme/coronavirus-vaccine/#booster-doses
Norwegian Institute of Public Health. Coronavirus vaccine – inforation
for the public. https://www.fhi.no/en/id/vaccines/coronavirusimmunisation-programme/coronavirus-vaccine/#booster-doses

PolandRecommendation:
Additional dose plus a booster dose for individuals 12 years or older(extended primary three-dose vaccination series plus a booster dose).
Timing:Additional dose given at least four weeks after second dose, followed by a booster
dose at least three months after third dose.

PortugalRecommendation:
Additional dose for individuals 12 years and over (extended primary threedose vaccination series).
For 18 years and over and additional dose plus a booster (extended primary
three-dose vaccination series).
Timing:Additional dose of mRNA vaccine given at least three months after second dose(minimum 28 days).

Recommendation:
One booster dose for individuals aged ≥18 years (two dose primary
vaccination series plus booster dose).
No general recommendation for second booster doses but people aged 80
and older who have received 3 doses and have not had COVID-19 sincethen, can receive a new booster dose if they wish.
Timing:Booster dose given at least 20 weeks after primary vaccination with mRNA-based
vaccines; COVID-19 Vaccine Janssen dose is followed by mRNA vaccine after at
least 8-12 weeks, followed by a booster with mRNA vaccine at least 20 weeks
after second dose.
Second booster dose (dose 4): four months after the last booster dose (dose3)
Recommendation:
One booster dose for individuals aged ≥12 years (two dose primary
vaccination series plus booster dose).
Two booster doses for people aged 80 and over (the full primary vaccination
schedule and the first booster dose with COVID-19 mRNA)
Timing:Booster dose given at least five months after primary vaccination; two months after
single dose of COVID-19 Vaccine Janssen.
Second booter: 150 days after an mRNA booster
Recommendation:
One booster dose for individuals aged ≥18 years (two dose primary
vaccination series plus booster dose).
Two booster doses for people aged 80 and over, residents of nursing
homes.
Timing:Booster dose of mRNA vaccine given six months (minimum four months) after thelast dose.Three months after primary vaccination with COVID-19 Vaccine Janssen.

Romania

Recommendation:
Additional dose for individuals (extended primary three-dose vaccination
series).
Timing:Additional dose given 28-120 days after second dose.

Recommendation:
One booster dose for individuals aged ≥12 years (two dose primary
vaccination series plus booster dose) especially for people at high risk of
exposure, vulnerable people and on request for those who have completed the full
vaccination course more than four months ago.
Two booster doses for people over 18 years of age upon request, according
to the National Comittee on Vaccination against COVID-19. People over 18
years of age who have been vaccinated with 3 doses of mRNA vaccine orheterologous regimen that includes Vaxzevria and mRNA vaccines, may receive,
upon request a fourth dose of Comirnaty at least 4 months after the third dose. For
those vaccinated with Jannsen and an additional dose of mRNA vaccine, thesecond booster is currently not recommended.
Two booster doses for people over age of 18 who have been vaccinatedagainst COVID-19 with 3 doses of mRNA vaccine

Polish Ministry of Health. Booster dose. 2022. Available at:https://www.gov.pl/web/szczepimysie/trzecia-dawka
Polish Ministry of Health. Second booster dose for people 80+. 2022.
Available at: https://www.gov.pl/web/zdrowie/druga-dawkaprzypominajaca-dla-osob-80

Portugal - Servico Nacional De Saude. Campanha de
Vacinação Contra a COVID-19. 2022. Available at:https://www.dgs.pt/normas-orientacoes-e-informacoes/normase-circulares-normativas/norma-n-0022021-de-30012021pdf.aspx
Portugal. National Health Service. Directorate-General for
Health. People over 80 and living in nursing homes will receive asecond booster dose. 2022. Available at: https://www.dgs.pt/emdestaque/pessoas-com-mais-de-80-anos-e-residentes-em-laresvao-receber-segunda-dose-de-reforco.aspx
andhttps://covid19.min-saude.pt/wpcontent/uploads/2022/06/Parecer-CTVC-Estrategia-reforcovacinal-antecipacao-2a-dose-ERPI-11.05.2022_pdf-1281kb.pdf
Romanian Government website. Platform programming for thethird dose has begun. 2021. Available at: https://vaccinarecovid.gov.ro/a-inceput-programarea-in-platforma-pentru-doza-aiii-a/
The Government of Romania. National Coordination Committee
for COVID-19 vaccination activities. Administration of the 4thdose of Comirnaty vaccine – Pfizer BioNTech. 2022. Available
at: https://vaccinare-covid.gov.ro/wpcontent/uploads/2022/05/20220511__vaccinare_doza_4.pdf
The Government of Romania. Doza de rapel – booster. 2022.
Available at: https://vaccinare-covid.gov.ro/doza-de-rapelbooster/Country

Recommendation and timing of additional doses and booster doses of
COVID-19 vaccination for individuals with weakened immune systems(i.e. immunocompromised and immunosuppressed)

Recommendation for booster doses of COVID-19 vaccination andtiming for the general population

References

Recommended for people over 60 years of age
Timing:Booster dose given at least four months after primary vaccination.
4th dose: at least four months after the 3rd dose

Slovakia

Recommendation:
Additional dose doses for individuals (extended primary three-dose
vaccination series).

Recommendation:
One booster dose for individuals aged ≥18 years (two dose primary
vaccination series plus booster dose).

Timing:Additional dose given at least four weeks after second dose.

Timing:Booster dose given at least three months after primary vaccination.

Slovenia

Recommendation:
Additional dose plus one booster dose for individuals (extended primary
three-dose vaccination series plus a booster dose)
Second booster dose for all particularly vulnerable chronic patients who
have already received three doses (two primary doses and a booster dose).
Timing:Additional dose given at least four weeks after second dose followed by a fourth
dose at least three months after the third dose.
Second booster dose at least 3 months after the 3rd dose.

Spain

Recommendation:
Additional dose plus one booster dose for individuals (extended primary
three-dose vaccination series plus a booster dose).
Timing:Additional dose given at least 28 days after second dose, followed by a booster
dose at least five months after the third dose.

Recommendation:
One booster dose for individuals ≥18 years and 12-17 years with chronic
diseases. Healthy individuals 12-17 years can choose to get a booster (2dose primary vaccination series plus booster dose).
Second booster dose (third dose) for people who have been vaccinated with theJanssen vaccine is also possible, but only when signing consent for off label use.
Timing:Booster dose given at least three months after primary vaccination with mRNA
vaccines or mixed schedule; at least two months after primary vaccination with
Vaxzevria or COVID-19 Vaccine Janssen.
Recommendation:
One booster dose for individuals ≥18 years prioritised from oldest to youngest
age groups (two dose primary vaccination series plus booster dose).
2 doses of primary series + 1 additional dose+ 1 booster doserecommended in high-risk population groups
Timing:Booster dose given at least five months after primary vaccination with mRNA
vaccines; at least three months after primary vaccination with Vaxzevria or COVID19 Vaccine Janssen.

SwedenRecommendation:
Additional dose plus two booster doses for individuals ≥18 years (extended
primary three-dose vaccination series, plus two booster doses).
Timing:Additional dose given at least two months after second dose, followed by a first
booster dose at least three months after third dose and a second booster dose atleast three months after the first booster dose.

Recommendation
One booster dose for individuals aged ≥18 years (two dose primary
vaccination series plus booster dose).
Two booster doses for individuals aged ≥65 years, LTCF residents, people whohave home care (hemtjänst) or home healthcare (hemsjukvård) , people ≥18 with
Down syndrome (two dose primary vaccination series plus two booster doses).
Timing:First booster dose given at least three months after primary vaccination and thesecond booster dose given four months after the first booster dose.

Ministry of Health Slovak Republic. Usmernenie Ministerstva
zdravotníctva Slovenskej republiky k aplikácii dodatočnej tretej
dávky mRNA vakcíny pre imunokompromitované osoby a tretej
posilňovacej dávky mRNA vakcíny pre ostatné osoby proti
ochoreniu COVID-19. 2021. Available at:https://www.health.gov.sk/Zdroje?/Sources/Covid19/Ockovanie/3-davka/MU-tretia-davka.pdf
Slovenia - Nacionalni institut za javno zdravje (National Institute for
Public Health). Priporočila za cepljenje proti COVID-19 2022.
Available at:https://www.nijz.si/sites/www.nijz.si/files/uploaded/priporocila_za_cep
ljenje_proti_covid_uskl_psc_apr_2021.pdf

Gobierno De España. Estrategia de vacunación COVID19 en
España. 2022. Available at:https://www.sanidad.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/vacunasCOVID19_Profesionales.
htm
Government of Spain. Strategy COVID-19 vaccination.
Proposal of administration of a second booster dose. Available
at:https://www.sanidad.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID19_Administracion_segunda_dosis_de_recuerdo.pdf
Public Health Agency of Sweden/Folkhälsomyndigheten.
Påfyllnadsdoser rekommenderas till alla över 18 år. 2022.
Available at: https://www.folkhalsomyndigheten.se/smittskyddberedskap/utbrott/aktuella-utbrott/covid-19/vaccination-motcovid-19/information-for-dig-om-vaccinationen/pafyllnadsdos/

Joint ECDC-WHO Regional Office for Europe Monkeypox
Surveillance Bulletin
20 July 2022

Contents
SURVEILLANCE SUMMARY

1

INTRODUCTION

2PURPOSE AND SCOPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

CASE DEFINITION (WHO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3CASE DEFINITION (ECDC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

KEY INDICATORS6IHR SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

MAPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

EPICURVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

SUMMARY TABLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

DEMOGRAPHICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

CLINICAL DESCRIPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

OUTCOME, HIV STATUS, HCW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25

SEXUAL ORIENTATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26

MICROBIOLOGICAL ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27

DISCLAIMERS AND ACKNOWLEDGMENTS

30

COPYRIGHT STATEMENT AND DISCLAIMERS . . . . . . . . . . . . . . . . . . . . . . . . . . .

30

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31i

SURVEILLANCE SUMMARY
A total of 10604 cases of monkeypox have been identified through IHR mechanisms and official publicresources up to 19 July 2022, 14:00, from 36 countries and areas throughout the European region.
Case-based data were reported for 9281 cases from 31 countries and areas to ECDC and the WHO
Regional Office for Europe through The European Surveillance System (TESSy), up to 19 July 2022,
10:00.
Of the 9281 cases reported in TESSy, 9276 were laboratory confirmed. Furthermore, where sequencing
was available, 150 were confirmed to be of the West African clade. The earliest date of symptom onset
was reported as 19 July 2022. The majority of cases were between 31 and 40 years-old (3841/9237- 42%) and male (9149/9197 - 99.5%). Among cases with known HIV status, 38% (923/2403) wereHIV-positive. The majority of cases presented with a rash (4726/5003 - 94.5%) and systemic symptoms
such as fever, fatigue, muscle pain, vomiting, diarrhea, chills, sore throat or headache (3269/5003 65%). 256 cases were hospitalised (8.1%), of which 114 cases required clinical care. One case wasadmitted to ICU. No cases were reported to have died. Some (31) cases were reported to be healthworkers, however no occupational exposure has been reported.

1

INTRODUCTIONPURPOSE AND SCOPE
This report provides an overview of the total number of cases of monkeypox identified by ECDC
and the WHO Regional Office for Europe through IHR mechanisms and official public resources andcase-based data through The European Surveillance System (TESSy) up to 19 July 2022.
The first summary table and maps (first two tabs) describe the number of cases identified throughthe different platforms. The following figures and tables describe national case-based data forsurveillance of monkeypox reported in TESSy from all the countries and areas of the WHO European
Region, including the 24 countries of the European Union (EU) and the additional three countries of
the European Economic Area (EEA).
Case Report Form Data are submitted through the case-based record type MPX to The European
Surveillance System (TESSy) database hosted at ECDC.

2

CASE DEFINITION (WHO)As of 24 June 2022
Cases of monkeypox should be reported to TESSy if they meet any of the WHO, ECDC or national casedefinitions.
Confirmed case
• Laboratory confirmed monkeypox virus by detection of unique sequences of viral DNA by
real-time polymerase chain reaction (PCR)1 and/or sequencing.
Probable case:• A person meeting the case definition for a suspected case
AND One or more of the following:• has an epidemiological link [prolonged2 face-to-face exposure in close proximity, including
health workers without appropriate PPE (gloves, gown, eye protection and respirator);
direct physical contact with skin or skin lesions, including sexual contact; or contact withcontaminated materials such as clothing, bedding or utensils] to a probable or confirmed caseof monkeypox in the 21 days before symptom onset;• has had multiple or anonymous sexual partners in the 21 days before symptom onset;• has detectable levels of anti-orthopoxvirus (OPXV) IgM antibody3 (during the period of 4 to 56
days after rash onset); or a four-fold rise in IgG antibody titre based on acute (up to day 5-7)
and convalescent (day 21 onwards) samples; in the absence of a recent smallpox/monkeypox
vaccination or other known exposure to OPXV;• has a positive test result for orthopoxviral infection (e.g. OPXV-specific PCR without
MPXV-specific PCR or sequencing) 1 .
Suspected case
• A person of any age presenting since 01 January 2022 with an unexplained acute rash or one ormore acute skin lesions
AND one or more of the following signs or symptoms:• headache, acute onset of fever (>38.5°C), lymphadenopathy (swollen lymph nodes), myalgia(muscle pain/body aches), back pain, asthenia (profound weakness)3AND for which the following common causes of acute rash or skin lesions do not fully explain the clinicalpicture:• varicella zoster, herpes zoster, measles, herpes simplex, bacterial skin infections, disseminatedgonococcus infection, primary or secondary syphilis, chancroid, lymphogranuloma venereum,
granuloma inguinale, molluscum contagiosum, allergic reaction (e.g., to plants); and any otherlocally relevant common causes of papular or vesicular rash.
N.B. It is not necessary to obtain negative laboratory results for listed common causes of rash illness inorder to classify a case as suspected. Further, if suspicion of monkeypox infection is high due to either
history and/or clinical presentation or possible exposure to a case, the identification of an alternate
pathogen which causes rash illness should not preclude testing for MPXV, as coinfections have been
identified.

Discarded case
• A suspected or probable case for which laboratory testing of lesion fluid, skin specimens orcrusts by PCR and/or sequencing is negative for MPXV1 .
• Conversely, a retrospectively detected probable case for which lesion testing can no longer beadequately performed (i.e., after the crusts fall off) and no other specimen is found PCR-positive,
would remain classified as a probable case.

1. PCR on a blood specimen may be unreliable and should also not be used alone as a first line
diagnostic test. If blood PCR is negative and was the only test done, this is not sufficient todiscard a case that otherwise meets the definition of a suspected for probable case. This applies
regardless of whether the blood PCR was for OPXV or MPXV specific.
2. Evidence is currently lacking as to the duration of exposure necessary for infection by
the respiratory route, including how it relates to the severity of the index case’s disease.
Characterization of this parameter is one of the goals of the case investigation form describedbelow
3. Serology can be used for retrospective case classification for a probable case in specificcircumstances such as when diagnostic testing through PCR of skin lesion specimens has notbeen possible, or in the context of research with standardized data collection. The primary
diagnostic test for monkeypox diagnosis is PCR of skin lesion material or other specimen suchas an oral or nasopharygeal swab as appropriate. Serology should not be used as a first line
diagnostic test.

4

CASE DEFINITION (ECDC)
Cases of monkeypox should be reported to TESSy if they meet any of the WHO, ECDC or national casedefinitions.
Confirmed case :• A person with a laboratory-confirmed monkeypox infection (1) monkeypox virus specific PCR
assay positive result or (2) orthopoxvirus-specific PCR assay positive result which is thenconfirmed by nucleotide sequence determination of the detected virus as MPXV) with symptom
onset since 1 March 2022.
Probable case :(1) A person with an unexplained rash1 on any part of their body AND one or more other symptom(s)of monkeypox infection2 with symptom onset since 1 March 2022
AND one of the following:• has a positive laboratory test result on orthopoxviral infection (e.g., orthopoxvirus-specificpositive PCR without sequencing, electron microscopy, serology);• has an epidemiological link to a confirmed or probable case of monkeypox in the 21 days before
symptom onset;• reports travel to MPX endemic countries in the 21 days before symptom onset;• is a person (of any sexual orientation) who had multiple or anonymous sexual partners in the 21days before symptom onset;• is a man who has sex with men.
OR(2) A person with an unexplained generalized or localized maculopapular or vesiculopustular rashwith centrifugal spread, with lesions showing umbilication or scabbing, lymphadenopathy andone or more other MPX-compatible symptoms2 .

1. Since EU/EEA countries are just starting to identify cases and if testing capacity is sufficient, theabove more sensitive case definition can be used. In countries with limited testing capacity fororthopoxviruses, the following description can be added to characterize the rash: ‘unexplained
localized or generalized maculopapular or vesiculopustular rash potentially with umbilicationor scabbing’.
2. Fever (usually higher >38.5°C), headache, back ache, fatigue, lymphadenopathy (localized or
generalized).
5KEY INDICATORSIHR SUMMARY
Table 1: Summary of number of cases of monkeypox identified through IHR mechanisms and official
public resources and reported to TESSy, European Region, 2022
Country/Area

Number of cases identified through IHR and
official public resources

Number of cases reported
through TESSy

Spain
United Kingdom
Germany
FranceNetherlands
Portugal
Italy
Belgium
Switzerland
IsraelAustria
SwedenIreland
NorwayDenmark
PolandHungary
Slovenia
Romania
GreeceMalta
Czechia
Finland
Luxembourg
Iceland
Croatia
Gibraltar
SerbiaEstonia
Bulgaria
LatviaSlovakia
Georgia
Russian Federation
TürkiyeBosnia and Herzegovina
Total

2835
2115
2033
912
656
515
374
312
208
102
88
71
69
44
43
40
32
26
19
18
17
14
13
10
7
6
5
5
4
3
2
2
1
1
1
1
10604

2653
2116
1859
350
547
351
374
312
195
0
88
71
69
43
43
40
32
23
19
18
17
14
13
10
7
6
0
0
2
3
2
2
1
0
0
1
9281

6

MAPS
ECDC Map
Map Figure 1a: Distribution of cases of monkeypox, European Region, TESSy, 2022, ECDC
borders7

WHO-EURO Map
Map Figure 1b: Distribution of cases of monkeypox, European Region, TESSy, 2022, wHO EUROborders8

EPICURVES
Date of notification is defined as the date when the case report is notified for the first time to the placeof notification, date of diagnosis is defined as the first date of clinical or laboratory diagnosis, and dateof onset as the date of onset of any symptoms.

Overall by date of notification
Figure 1: Overall number of cases of monkeypox, per date of notification, European Region,
TESSy, 2022
500

300

200

100

Ap

r-2

8
r-3
M 0
ay
-0
M 2
ay
-0
M 4
ay
-0
M 6
ay
-0
M 8
ay
-1
M 0
ay
-1
M 2
ay
-1
M 4
ay
-1
M 6
ay
-1
M 8
ay
-2
M 0
ay
-2
M 2
ay
-2
M 4
ay
-2
M 6
ay
-2
M 8
ay
-3
0
Ju
n01
Ju
n03
Ju
n05
Ju
n07
Ju
n09
Ju
n11
Ju
n13
Ju
n15
Ju
n17
Ju
n19
Ju
n21
Ju
n23
Ju
n25
Ju
n27
Ju
n29
Ju
l-0
1
Ju
l-0
3
Ju
l-0
5
Ju
l-0
7
Ju
l-0
9
Ju
l-1
1
Ju
l-1
3
Ju
l-1
5
Ju
l-1
7
Ju
l-1
9
Ju
l-2
1

0

Ap

Number of new cases

400

Date of notification

9

Overall by date of symptom onset
Figure 2: Overall number of cases of monkeypox, per date of symptom onset, European Region,
TESSy, 2022

200

100

1
l-2

4
Ju

l-1

7
Ju

l-0

30
n-

Ju

23
n-

Ju

16
n-

Ju

09
n-

Ju

02

Ju

n-

6

Ju

-2

9

ay
M

-1

2

ay
M

-1

5

ay
M

-0

8

ay

r-2

M

1
Ap

r-2

4
Ap

r-1

7
Ap

r-0
Ap

ar

-3

1

0

M

Number of new cases

300

Day of symptom onset (or earliest of day of diagnosis or notification if missing)
Diagnosis

Notification

10

Onset

By date of onset and by country or area

Austria

Estonia

Iceland

NorwaySwedenBelgium

Finland

Ireland

PolandSwitzerland

Bosnia and Herzegovina

France

Italy

Portugal

United Kingdom

Bulgaria

Georgia

LatviaRomania

Croatia

Germany

Luxembourg

Slovakia

Czechia

GreeceMalta

Slovenia

Denmark

Hungary

Netherlands

Spain

300

200

100

1
l-2

4
Ju

l-1

7
Ju

l-0

Ju

30
n-

23

Ju

n-

16

Ju

n-

09

Ju

n-

02

Ju

n-

-2
ay

M

Ju

6

9
-1

2

ay
M

-1

5

ay

M

-0

8

ay

r-2

M

1
Ap

r-2

4
Ap

r-1

7
Ap

r-0
Ap

ar

-3

1

0

M

Number of new cases

Figure 3: Number of cases of monkeypox, per day and per country/area of notification, European
Region, TESSy, 2022

Day of symptom onset (or earliest of day of diagnosis or notification if missing)11Day of symptom onset*

12
Day of symptom onset*

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

0

r-0

0

Ap

25

Ap

25

9

75

2

75

r-2

100

r-0

AustriaAp

50

Number of new cases

100

Ma

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

Ap

Ap

9

2

r-2

r-0

Ap

Ma

Number of new cases

By date of onset and by country or area - country/area level

Figure 4: Number of cases of monkeypox, per day and per country/area of notification, European Region, TESSy, 2022
Belgium

50

9

r-2

9

r-2

Day of symptom onset*

13
Day of symptom onset*

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Day of symptom onset*

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

0

Ma
y-0

0

4

25

Ma
y-0

25

Ap
r-3
0

75

Ap
r-2
6

75

Ap
r-2
2

100

Ap
r-1
8

Croatia

Ap
r-1
4

100

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

0

Ap

0

Ap

25

Ap
r-1
0

25

Ap
r-0
6

9

75

2

r-2

75

r-0

100

Ap

Ma

Number of new cases

Bosnia and Herzegovina

Ap
r-0
2

50

Number of new cases

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

Ap

Ap

9

2

r-2

r-0

Ap

Ma

Number of new cases

50

Ma

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

Ma
y-0

4

Ma
y-0

Ap
r-3
0

Ap
r-2
6

Ap
r-2
2

Ap
r-1
8

Ap
r-1
4

Ap
r-1
0

Ap
r-0
6

Ap
r-0
2

Ma

Number of new cases

100

Bulgaria

50

Day of symptom onset*

Czechia

50

9

r-2

9

r-2

Day of symptom onset*

14
Day of symptom onset*

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Day of symptom onset*

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

0

Ma
y-0

0

4

25

Ma
y-0

25

Ap
r-3
0

75

Ap
r-2
6

75

Ap
r-2
2

100

Ap
r-1
8

Finland

Ap
r-1
4

100

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

0

Ap

0

Ap

25

Ap
r-1
0

25

Ap
r-0
6

9

75

2

r-2

75

r-0

100

Ap

Ma

Number of new cases

Denmark

Ap
r-0
2

50

Number of new cases

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

Ap

Ap

9

2

r-2

r-0

Ap

Ma

Number of new cases

50

Ma

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

Ma
y-0

4

Ma
y-0

Ap
r-3
0

Ap
r-2
6

Ap
r-2
2

Ap
r-1
8

Ap
r-1
4

Ap
r-1
0

Ap
r-0
6

Ap
r-0
2

Ma

Number of new cases

100

Estonia50

Day of symptom onset*

France

50

9

r-2

9

r-2

Day of symptom onset*

15
Day of symptom onset*

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Day of symptom onset*

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

0

Ma
y-0

0

4

25

Ma
y-0

25

Ap
r-3
0

75

Ap
r-2
6

75

Ap
r-2
2

100

Ap
r-1
8

Greece

Ap
r-1
4

100

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

0

Ap

0

Ap

25

Ap
r-1
0

25

Ap
r-0
6

9

75

2

r-2

75

r-0

100

Ap

Ma

Number of new cases

Georgia

Ap
r-0
2

50

Number of new cases

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

Ap

Ap

9

2

r-2

r-0

Ap

Ma

Number of new cases

50

Ma

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

Ma
y-0

4

Ma
y-0

Ap
r-3
0

Ap
r-2
6

Ap
r-2
2

Ap
r-1
8

Ap
r-1
4

Ap
r-1
0

Ap
r-0
6

Ap
r-0
2

Ma

Number of new cases

100

Germany

50

Day of symptom onset*

Hungary

50

9

r-2

9

r-2

Day of symptom onset*

16
Day of symptom onset*

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Day of symptom onset*

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

0

Ma
y-0

0

4

25

Ma
y-0

25

Ap
r-3
0

75

Ap
r-2
6

75

Ap
r-2
2

100

Ap
r-1
8

Italy

Ap
r-1
4

100

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

0

Ap

0

Ap

25

Ap
r-1
0

25

Ap
r-0
6

9

75

2

r-2

75

r-0

100

Ap

Ma

Number of new cases

Iceland

Ap
r-0
2

50

Number of new cases

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

Ap

Ap

9

2

r-2

r-0

Ap

Ma

Number of new cases

50

Ma

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

Ma
y-0

4

Ma
y-0

Ap
r-3
0

Ap
r-2
6

Ap
r-2
2

Ap
r-1
8

Ap
r-1
4

Ap
r-1
0

Ap
r-0
6

Ap
r-0
2

Ma

Number of new cases

100

Ireland50

Day of symptom onset*

Latvia

50

9

r-2

9

r-2

Day of symptom onset*

17
Day of symptom onset*

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Day of symptom onset*

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

0

Ma
y-0

0

4

25

Ma
y-0

25

Ap
r-3
0

75

Ap
r-2
6

75

Ap
r-2
2

100

Ap
r-1
8

Netherlands

Ap
r-1
4

100

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

0

Ap

0

Ap

25

Ap
r-1
0

25

Ap
r-0
6

9

75

2

r-2

75

r-0

100

Ap

Ma

Number of new cases

Luxembourg

Ap
r-0
2

50

Number of new cases

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

Ap

Ap

9

2

r-2

r-0

Ap

Ma

Number of new cases

50

Ma

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

Ma
y-0

4

Ma
y-0

Ap
r-3
0

Ap
r-2
6

Ap
r-2
2

Ap
r-1
8

Ap
r-1
4

Ap
r-1
0

Ap
r-0
6

Ap
r-0
2

Ma

Number of new cases

100

Malta

50

Day of symptom onset*

Norway

50

9

r-2

9

r-2

Day of symptom onset*

18
Day of symptom onset*

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Day of symptom onset*

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

0

Ma
y-0

0

4

25

Ma
y-0

25

Ap
r-3
0

75

Ap
r-2
6

75

Ap
r-2
2

100

Ap
r-1
8

Romania

Ap
r-1
4

100

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

0

Ap

0

Ap

25

Ap
r-1
0

25

Ap
r-0
6

9

75

2

r-2

75

r-0

100

Ap

Ma

Number of new cases

Poland

Ap
r-0
2

50

Number of new cases

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

Ap

Ap

9

2

r-2

r-0

Ap

Ma

Number of new cases

50

Ma

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

Ma
y-0

4

Ma
y-0

Ap
r-3
0

Ap
r-2
6

Ap
r-2
2

Ap
r-1
8

Ap
r-1
4

Ap
r-1
0

Ap
r-0
6

Ap
r-0
2

Ma

Number of new cases

100

Portugal50

Day of symptom onset*

Slovakia

50

9

r-2

9

r-2

Day of symptom onset*

19
Day of symptom onset*

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Day of symptom onset*

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

0

Ma
y-0

0

4

25

Ma
y-0

25

Ap
r-3
0

75

Ap
r-2
6

75

Ap
r-2
2

100

Ap
r-1
8

Sweden

Ap
r-1
4

100

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

0

Ap

0

Ap

25

Ap
r-1
0

25

Ap
r-0
6

9

75

2

r-2

75

r-0

100

Ap

Ma

Number of new cases

Slovenia

Ap
r-0
2

50

Number of new cases

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

Ap

Ap

9

2

r-2

r-0

Ap

Ma

Number of new cases

50

Ma

-23

Jul

-19

Jul

-15

Jul

-11

Jul

-07

Jul

-03

Jul

Jun
-29

Jun
-25

Jun
-21

Jun
-17

Jun
-13

Jun
-09

Jun
-05

-01

Jun

8

Ma
y-2

4

Ma
y-2

0

Ma
y-2

6

Ma
y-1

2

Ma
y-1

8

Ma
y-0

4

Ma
y-0

Ap
r-3
0

Ap
r-2
6

Ap
r-2
2

Ap
r-1
8

Ap
r-1
4

Ap
r-1
0

Ap
r-0
6

Ap
r-0
2

Ma

Number of new cases

100

Spain

50

Day of symptom onset*

Switzerland

50

-23

-19

Jul

Jul

-15

-11

Jul

Jul

-07

-03

Jul

Jul

-29

Jun

-25

Jun

-21

Jun

-17

Jun

-13

Jun

-09

Jun

-05

Jun

-01

Jun

8

4

y-2

Ma

y-2

Ma

0

6

y-2

Ma

y-1

Ma

2

8

y-1

Ma

y-0

Ma

4

0

y-0

Ma

r-3

Ap

6

2

r-2

Ap

r-2

Ap

8

4

r-1

Ap

r-1

Ap

0

6

r-1

r-0

Ap

Ap

9

2

r-2

r-0

Ap

Ma

Number of new cases

100

United Kingdom

75

50

25

0

Day of symptom onset**Day of symptom onset or earliest of day of diagnosis or notification if missing

20

SUMMARY TABLE
Table 2: Summary of number of probable and confirmed cases of monkeypox by country/area,
European Region, TESSy, 2022
Country

Confirmed cases

Probable cases

Unclassified cases

Total cases

Austria
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Czechia
Denmark
Estonia
FinlandFranceGeorgia
Germany
GreeceHungary
Iceland
IrelandItaly
LatviaLuxembourg
Malta
Netherlands
NorwayPolandPortugal
Romania
Slovakia
Slovenia
Spain
SwedenSwitzerland
United Kingdom
Total

88
311
1
3
6
14
43
2
13
350
1
1859
18
32
7
69
374
2
10
17
547
43
36
351
19
2
23
2653
71
195
2116
9276

0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4
0
0
0
0
0
0
0
0
5

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

88
312
1
3
6
14
43
2
13
350
1
1859
18
32
7
69
374
2
10
17
547
43
40
351
19
2
23
2653
71
195
2116
9281

21

DEMOGRAPHICS

Over 60 years-old

251-60 years-old

541-50 years-old

931-40 years-old

14

18-30 years-old

17

0-17 years-old

1

5

0
0

20

168

809

2274

3799

00
16
00
18
00
20
00
22
00
24
00
26
00
28
00
30
00
32
00
34
00
36
00
38
00
40
00

00

14

12

0

00

10

0

80

0

60

0

2063

40

10

Age groups

Figure 6: Age and gender distribution of cases of monkeypox, European Region, TESSy, 2022

Number of cases
FemaleMale

Information on gender is missing for 84 cases and information on age is missing for 44 cases.

22

CLINICAL DESCRIPTION
The average time between symptom onset and diagnosis was 7 days.
Figure 7: Distribution of symptoms among those reporting at least one type of symptom (N=5003), European Region, TESSy, 2022

n=4726 (94.5%)

Any type of rashn=3269 (65.3%)

Systemic symptoms*
n=2139 (42.8%)

Skin/mucosal lesions (excl. oral or anogenital areas)

n=1948 (38.9%)

Anogenital dermatological lesions

n=1489 (29.8%)
n=1256 (25.1%)

Localized lymphadenopathy

23

00
60

00
55

00

10
0

50

50

n=2 (0%)00

Asymptomatic45

n=5 (0.1%)

00

Sensitivity to light40

n=10 (0.2%)

15

Conjunctivitis

0

n=17 (0.3%)

0Anal/rectal pain and/or rectal bleeding00

n=130 (2.6%)

35

Respiratory symptoms

00n=182 (3.6%)

00

Other

30

n=484 (9.7%)00

Lymphadenopathy, location unknown

25

n=500 (10%)

20

Generalized lymphadenopathy

00

n=597 (11.9%)

Oral dermatological lesions

0

Number of cases

Rash, unknown location

Distribution of rash and systemic symptoms among those reporting at least one type ofsymptom (N=5003), European Region, TESSy, 2022
Table 3: Distribution of rash and systemic symptoms among those reporting at least one type ofsymptom (N=‘r nrow(ClinicalData)‘), European Region, TESSy, 2022
Any type of rash

Systemic Symptoms*

Count (%)

Present
Present
AbsentAbsentTotal

Present
AbsentPresent
Absent-3036 (60.7%)1690 (33.8%)233 (4.7%)
44 (0.9%)5003 (100%)*Fever, fatigue, muscle pain, vomiting, diarrhea, chills, sore throat, headache
Detection of asymptomatic cases is dependent on testing guidelines which currently do not recommend
testing asymptomatic persons

24

OUTCOME, HIV STATUS, HCW
Table 4: Summary of outcome, HIV status of cases, and cases of monkeypox among health workers,
European Region, TESSy, 2022

Admitted to ICU
Hospitalized*
Died
HIV-Positive
Health worker

Yes

No

Total

1 (0.1%)256 (8.1%)
0 (0.0%)923 (38.4%)
31 (2.6%)

1359 (99.9%)2919 (91.9%)5237 (100%)
1480 (61.6%)
1167 (97.4%)

1360 (100%)
3175 (100%)
5237 (100%)
2403 (100%)
1198 (100%)*Includes cases hospitalized for isolation or treatment (51 cases were hospitalized for isolation
purposes,114 required clinical care and 91 were hospitalized for unknown reasons).

25

SEXUAL ORIENTATION
Sexual orientation in TESSy is defined according to the following non-mutually exclusive categories:• Heterosexual• MSM = MSM/homo or bisexual male
• Women who have sex with women• Bisexual• Other• Unknown or undetermined
Sexual orientation is not necessarily representative of the gender of the person the case had sex within the past 21 days nor does it imply sexual contact and sexual transmission.
We summarize here the sexual orientation that male cases identified with. No differences wereobserved across age groups.
Table 5: Summary of reported sexual orientations among cases of monkeypox, European Region,
TESSy, 2022
Sexual Orientation

Count (%)

MSM
3124 (33.7%)
Bisexual
33 (0.4%)
Heterosexual
46 (0.5%)
Unknown or undetermined 1508 (16.2%)
Missing
4570 (49.2%)
Total9281 (100%)26

MICROBIOLOGICAL ANALYSESSPECIMEN TYPES
Table 6: Summary of specimen types with positive test result used for diagnosis of monkeypox,
European Region, TESSy, 2022
Specimen typeCount

Lesion swab
285 (46.5%)
Oropharyngeal swab 128 (20.9%)
Rectal swab
96 (15.7%)
Lesion crust
74 (12.1%)
Genital swab
23 (3.8%)Urine
7 (1.1%)Serum
0 (0.0%)Semen
0 (0.0%)Total
613 (100%)PHYLOGENETICS
Phylogenetics of monkeypox virus
Whole genome sequences of MPXV were extracted from GISAID EpiPox and NCBI GenBank on 18 July
2022. NextClade [1] was used to assess the quality and poor-quality sequences were excluded. The
phylogenetic analysis was performed using ParSNP [2] with MT903344.1 as reference and visualizedusing Microreact [3].
There are two genetically distinct major clades described for MPXV, the Central African (Congo Basin)
and West African clades (Figure A).
The 2022 outbreak sequences from Europe are part of a distinct cluster within the West African clade
and cluster together with 2022 MPXV sequences from Australia, Brazil, Canada, Mexico, Peru, South
Africa, Taiwan, and the United States (Figure B). Two 2022 sequences from the United States do notcluster with the other outbreak sequences. Available information indicate that these are sporadic
cases not linked to the current outbreak.
The most recently (since 11 July 2022) deposited sequences collected in 2022 are from Austria, Canada,
Czechia, Mexico, Netherlands, Peru and the United States and are all part of the 2022 outbreak within
the distinct West African clade (Figure B).

27

Figure A. Phylogenetic tree of monkeypox virus sequences as of 18 July 2022.

28

Figure B. Phylogenetic tree of monkeypox virus sequences from West African clade as of 18 July 2022. Sequences from 2022 areindicated with coloured circles and the binary heatmap shows new sequences uploaded to sequence databases after 11 July 2022.

29

[1] Aksamentov, I., Roemer, C., Hodcroft, E. B., & Neher, R. A., (2021). Nextclade: clade assignment,
mutation calling and quality control for viral genomes. Journal of Open Source Software, 6(67), 3773,
https://doi.org/10.21105/joss.03773[2] Treangen TJ, Ondov BD, Koren S, Phillippy AM. The Harvest suite for rapid core-genome alignment
and visualization of thousands of intraspecific microbial genomes. Genome Biology. 2014;15(524).
Available at: https://genomebiology.biomedcentral.com/articles/10.1186/s13059-014-0524-x[3] Argimón S, et al. Microreact: visualizing and sharing data for genomic epidemiology andphylogeography. Microbial Genomics. 2016;2(11). Available at: https://www.microbiologyresearch.
org/content/journal/mgen/10.1099/mgen.0.000093

DISCLAIMERS AND ACKNOWLEDGMENTS
COPYRIGHT STATEMENT AND DISCLAIMERS
Users are advised to interpret all data with caution and be aware of their limitations. Case counts
and their corresponding data may have weekly updates that include historical corrections as new
information is collected and reported.
The designations employed and the presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part of WHO or ECDC concerning the legal status of any
country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers orboundaries.
The mention of specific companies or of certain manufacturers’ products does not imply that they areendorsed or recommended by WHO or ECDC in preference to others of a similar nature that are notmentioned. Errors and omissions excepted, the names of proprietary products are distinguished byinitial capital letters.
All reasonable precautions have been taken by WHO and ECDC to verify the information contained inthis publication. However, the published material is being distributed without warranty of any kind,either expressed or implied. The responsibility for the interpretation and use of the material lies withthe reader. In no event shall WHO or ECDC be liable for damages arising from its use. Copyright,
permissions and referencing The WHO Regional Office for Europe is responsible for the accuracy of
the Russian translation.
Suggested citation: European Centre for Disease Prevention and Control/WHO Regional Office forEurope. Monkeypox, Joint Epidemiological overview, 20 July, 2022.
Tables and figures should be referenced: European Centre for Disease Prevention and Control/WHO
Regional Office for Europe. Monkeypox, Joint Epidemiological overview, 20 July, 2022.
30

© World Health Organization 2022.
© European Centre for Disease Prevention and Control 2022.
Some rights reserved. This work is available under the Creative Commons Attribution- 4.0
International (CC BY-4.0 ; Creative Commons — Attribution 4.0 International — CC BY 4.0. In any
use of this work, there should be no suggestion that WHO or ECDC endorse any specific organization,
products or services. The use of the ECDC or WHO logo is not permitted. If you create a translationof this work, you should add the following disclaimer along with the suggested citation: “Thistranslation was not created by the European Centre for Disease Prevention and Control (ECDC) or by
the World Health Organization (WHO). ECDC and WHO are not responsible for the content or accuracyof this translation. The original English edition shall be the binding and authentic edition.

ACKNOWLEDGMENTS
We gratefully acknowledge the input of national public health staff involved in surveillance activities
and data submission to TESSy, as well as the following authors from the originating laboratories
responsible for obtaining the specimens, as well as the submitting laboratories where the genome
data were generated and shared via GISAID, on which this research is based.
A full list of acknowledgements for the genome data used in this report can be found in theacknowledgements section of the web version of this report at https://monkeypoxreport.ecdc.
europa.eu/.

31

KEEPING AGENTS SAFE ON BOARD
INFECTIOUS DISEASES PROTOCOLS FOR SHIP AGENTS
INTRODUCTION
The COVID-19 pandemic has amply demonstrated both the impact a “public health emergency ofinternational concern”, (as defined in the WHO’s International Health Regulation) can have on theinternational maritime sector and the resilience, flexibility, and ingenuity of that sector in adapting to thechanged circumstances and ensuring that goods continue to move.
The pandemic has also accelerated the use of digital technology and the streamlining of procedures toreduce the levels of personal contact required to ensure the requirements and obligations of the ship-portinterface can be carried out, whilst also reducing opportunities for the spread of a communicable disease
between the ship and shore. At the same time, concerns about the detrimental impact on the mental healthof seafarers resulting from the cancellation of crew changes, reduced human contact and bans on shore
leave, have increased significantly.
As the primary contact between the ship and the shore, the ship agent is deeply involved in all these issues
and their continued engagement on operational, husbandry and pastoral matters is vital in keeping ships
moving and international trade flowing, whilst also addressing the needs of the crew.
To ensure that ship agents can continue to provide the highest and widest possible levels of service to ships
and their crews during the ongoing COVID-19 pandemic and any future public health emergency ofinternational concern therefore, FONASBA has drafted these protocols.
COMPLIANCE WITH EXISTING REGULATIONS:The ship agent operates alongside, and in concert with, all the stakeholders in the ship-to-shore interface
and therefore complies with all necessary requirements, regulations and protocols including, but notlimited to: the World Health Organisation International Health Regulations 2005, the International Maritime
Organisation Convention on Facilitation of International Maritime Traffic (the IMO FAL Convention), theEuropean Commission Guidelines for Border Management Measures to Protect Health and Ensure the
Availability of Goods and Essential Services (C2020/1753), the International Chamber of Shipping Guidance
for Ensuring a Safe Shipboard Interface Between Ship and Shore-based Personnel (IMO Circular Letter
4024/Add.16) and additionally guidance, protocols and requirements issued by national authorities,
shipowners, port authorities and terminal operators. These FONASBA protocols are designed to operate
alongside, and compliment, existing guidance, protocols, and requirements, but are not intended tooverride or supersede them, especially where they have legal effect.

METHODOLOGY:
For the sake of consistency, these protocols are based on the “Hierarchy of controls as a guide toestablishing effective safety control measures and reducing risk” as detailed in the International Chamberof Shipping’s publication Guidance for Ensuring a Safe Shipboard Interface Between Ship and Shore-based
Personnel mentioned above and endorsed by FONASBA. We are grateful to the International Chamber for
permission to use the Hierarchy of Controls as a basis for these protocols.
FONASBA/London, July 2022

© FONASBA 2022

FONASBA Infectious Diseases Protocols for Ship Agents, July 2022

HIERARCHY OF CONTROLS1:
1. Eliminate

Elimination of the hazard is the most effective measure to reducerisks.
Work onboard should not be conducted if there is a safer method
to undertake the task, such as not going to a ship. In a number of
instances, e.g. conducting audit, surveys inspections and training,
remote possibilities exist which may eliminate the need to go
onboard or reduce the numbers of personnel needing to attend.

2. Reduce

Can attendance onboard be reduced?
Where it is not possible to fully eliminate the hazards, the risk
could be reduced by minimising the onboard element of the work.

3. Communicate

If onboard attendance of shore-based personnel cannot be
eliminated, communicate, and understand participant
requirements.
Ensure requirements of each party, the ship and shore-basedorganisation have been communicated in good time to each otherand are assessed and understood.
If there are differences in requirements, control measures shouldbe agreed and understood by all parties prior to the shipboard
intervention taking place.

4. Control

If the requirements of each party, the ship and the shore-basedorganisation have been communicated to each other andassessed, and are either not understood or there are differences,measures need to be taken so that all requirements areunderstood and so that requirements can be mutually agreed andunderstood by all parties prior to the shipboard intervention
taking place.

5. PersonalProtective
Equipment(PPE)

Understand what PPE is required and expected to be used by crew
and shore-based personnel during attendance on board and at
what times.

1 Taken from the International Chamber of Shipping’s publication “Guidance for Ensuring a Safe Shipboard

Interface Between Ship and Shore-based Personnel” and reproduced with permission of the Chamber.

© FONASBA 2022

FONASBA Infectious Diseases Protocols for Ship Agents, July 2022

ACTIONS BY THE SHIP AGENT
1. Eliminate

Elimination of the hazard is Action should be taken by the agent to minimise unnecessary in-person contact with thethe most effective measure to vessel as a means of reducing the likelihood of transmission of the disease from the ship
to shore or vice versa. At all times however, the agent must be mindful that one of their
reduce risks.
obligations is to provide appropriate pastoral care to the Master and crew. The rightWork onboard should not bebalance must therefore be struck between minimising contact and ensuring the crew
conducted if there is a safer
receive the pastoral care they deserve.
method to undertake the task,such as not going to a ship. In Where possible therefore:
a number of instances, e.g.
 The exchange of documents and other operational information should be undertaken
conducting audit, surveys
remotely
inspections and training, Physical attendance on the vessel should be limited to the minimum number ofremote possibilities exist
personnel required to carry out the tasks concerned
which may eliminate the need Contact with crew members should involve only those crew members and shore-based
to go onboard or reduce thestaff directly relevant to the matter under discussion
numbersofpersonnel
 Meetings should be strictly time-limited to further reduce possible exposureneeding to attend.
 Visits to the vessel should be scheduled to minimise contact between different parties
 Visitors to the vessel should use their own transport and avoid having other parties
travelling in the same vehicle
 Consideration should be given to meetings being held remotely, or outside theaccommodation block where unavoidable
By eliminating the risk of cross-transmission of infections in other areas, and efficiently
addressing the necessary administrative tasks, as detailed above, it is anticipated the agent
will be able to devote appropriate time to the husbandry and pastoral needs of the crew.

© FONASBA 2022

FONASBA Infectious Diseases Protocols for Ship Agents, July 2022

2. Reduce

Can attendance onboard be The examples of elimination strategies detailed in section 1 above will, if implemented
correctly, significantly reduce the levels of contact between the ship and shore andreduced?
therefore minimise the risks of cross-infection. Any reduction in contact should however
Where it is not possible tobe assessed in the context of maintaining a minimum level of physical attendance at the
fully eliminate the hazards,
vessel, consistent with the ship agent’s ability to provide adequate and appropriate service
the risk could be reduced byto the shipowner or operator, and the crew.
minimising the onboard
element of the work.

3. Communicate

If onboard attendance ofshore-based
personnel
cannotbeeliminated,
communicate and understandparticipant requirements.

Communication between the ship, the operator, the charterer and shore-based service
providers is key to the effective and efficient operation and administration of the port call.
The need to additionally communicate infectious disease prevention and mitigation
information and guidance should be fully integrated into the pre-call communication
planning, with emphasis being placed on ensuring the earliest possible advice ofappropriate measures in place onboard the vessel and in the port, including:

Ensure requirements of eachparty, the ship and shore- 
based organisation have beencommunicated in good time to each other and areassessed and understood.

If there are differences in 
requirements,
controlmeasures should be agreed
and understood by all parties prior to the shipboard intervention taking place.

© FONASBA 2022

Full information on all relevant disease mitigation protocols and regulations, including
policies on the use of PPE (see control 5 below)
Information on cases of illness on board the vessel and any visits to healthcare
professionals that may be required
Details and results of tests taken by the crew, passengers, and shore-based visitors
Information on the procedures, protocols and limitations relating to crew changes,
both on and off-signing, and the precautions to be taken by arriving and departing crew
members
A schedule of planned visits to the vessel and the number of persons involved
Information on any other visits, inspections, surveys, deliveries organised for the port
concerned by the ship owner, operators or charterer, and the relevant contact details
to allow same to be integrated into the visit plan
Details of how cargo operations will be managed

FONASBA Infectious Diseases Protocols for Ship Agents, July 2022

Procedures for the remote exchange of documentation and for signing (if required)
Any additional information specific to the port, the vessel, the crew, and/or the call

4. Control

If the requirements of eachparty, the ship and the shorebased organisation have beencommunicated to each otherand assessed, and are either
not understood or there aredifferences, measures need tobe taken so that all
requirements are understoodand so that requirements canbe mutually agreed andunderstood by all parties
prior to the shipboard
intervention taking place.

Ensuring that all parties are fully informed of all aspects of the port call and the relevant
procedures and protocols, and can apply them at the correct time, is vital to avoiding any
confusion, conflicts, and other delays. Starting that conversation as early as possible after
the destination country and/or port range are known, will allow for the fullest possible
time for clarification and explanation to be provided where necessary, and the required
procedures implemented. It will also ensure that all parties are fully briefed in advanceand therefore able to carry out their obligations efficiently and effectively and withminimal interruption to the port call and cargo operations.

5. PersonalProtective
Equipment(PPE)

Understand what PPE is
required and expected to be
used by crew and shorebased
personnel
duringattendance on board and at
what times.

Information on company policies (both ship and shore) regarding the use of PPE and its
disposal should be included as part of the initial information exchange, ensuring that boththe crew and shore-based visitors are fully equipped prior to visits taking place. Again, any
questions or concerns about its availability and use can be addressed in sufficient time to
avoid any delays.

© FONASBA 2022

Whilst evidence for surface-based transmission of infections (that is through touchingsurfaces and materials where viruses may be present) is not conclusive, good practicewould indicate that appropriate precautionary actions, such as regular cleaning and

FONASBA Infectious Diseases Protocols for Ship Agents, July 2022

disinfecting, should be put in place to mitigate any risks from, for example, the handling of
paper, touching door handles and guardrails© FONASBA 2022

FONASBA Infectious Diseases Protocols for Ship Agents, July 2022

JSA UPDATESNew requirement for inbounds from June 1, 2022
The government announced that they would change the criteria for inbound people who
may enter Japan by air effective from June 1, 2022.
Before departure from their home countries
Regardless of the countries’ categories by the Japanese quarantine authority, all seafarers
coming from all countries and areas shall follow the following criteria.
Persons who are going to visit Japan shall get a negative certificate of COVID-19 test (PCR
test or other method authority allows) seventy-two (72) hours before flight departure.
On-arrival Testing at the airport
Red category:Yes
Yellow-category(Not boosted):
Yes(Boosted):No
Blue-category:No

Note: Persons who may be positive by the airport testing cannot pass animmigration check until released (7 days at least).
Required Isolation after arrival
Red category(Not boosted): Three days in designated accommodation. The third-day testing is required.
They cannot use public transportation after the third-day testing (negative results). Afterthen they can move to their domestic destination using public transportation.
Red category(Boosted): Basically, three (3) days in accommodation.
Yellow-category(Not boosted): Basically, three (3) days in accommodation.
They may transfer to the hotel (or to the vessel) using public transportation within 24 hours
after testing (specimen collection) at the airport. After the isolation period (3 days), they
may move to the destination using public transportation (using non-public transportation isrecommended).
Yellow-category
Provided by the Japanese Shipowners’ Association

(Boosted): Not required
Blue-category: Not required
They may move to the destination any time after arrival. They may use public
transportation.
For details, kindly refer to the following URL:
https://www.mofa.go.jp/ca/cp/page22e_000925.html
Categories as of July 27
Red-category Countries
Albania, and Sierra Leone (in no order)
Yellow-category Countries[Asia & Oceania]
India, North Korea, Kiribati, Cook Islands, Samoa, Sri Lanka, Solomon Islands, Tuvalu,
Tonga, Nauru, Niue, Pakistan, Vanuatu, Fiji, Bhutan, Brunei, Vietnam, Marshall Islands,
Macau, Micronesia, and the Maldives.
[North America]
None[Middle & South America]
Antigua and Barbuda, Uruguay, Guyana, Cuba, Grenada, Suriname, Saint Kitts, and Nevis,
Saint Vincent and the Grenadines, Saint Lucia, Dominica, Trinidad and Tobago, Nicaragua,
Haiti, Bahamas, Barbados, Venezuela, Belize, and Honduras[Europe]Andorra, Ukraine, Uzbekistan, Kazakhstan, North Macedonia, Cyprus, Kosovo, San Marino,
Georgia, Tajikistan, Turkmenistan, Vatican City, Belarus, Portugal, Malta, and
Liechtenstein.
[Middle East & Africa]
Angola, Yemen, Egypt, Eswatini, Eritrea, Oman, Cape Verde, Gabon, Gambia, Guinea,
Guinea-Bissau, Kuwait, Comoros, Republic of the Congo, the Democratic Republic of theCongo, Saudi Arabia, São Tomé and Príncipe, Syria, Zimbabwe, Sudan, Seychelles,
Equatorial Guinea, Senegal, Somalia, Chad, Central African Republic, Tunisia, Togo,
Turkey, Namibia, Niger, Palestine, Burkina Faso, Burundi, Botswana, Mali, Mauritius,
Mauritania, Libya, Liberia, Lesotho, and Lebanon (in no particular order)
Blue-category Countries
Other than the above-listed countries

Provided by the Japanese Shipowners’ Association